iw'-v;-'.; 



5' 



I 




Qass 
Book 



COPYRIGHT DEPOSIT 



MINOR SUEGEKY; 



HINTS 



EVERY-DAY DUTIES OF THE SURGEON. 



Co 



HENRY H. SMITH, M.D., 

Lecturer on the Practice of Surgery.; Fellow of the College of Physicians ; 
Member of the Philadelphia Medical Society, etc. 



SECOND EDITION, WITH NUMEROUS ADDITIONS. 



XUustrateli bv 227 iBnflrabinfls. 



k 



PHILADELPHIA: 

ED. BARRINGTON & GEO. D. HASWELL. 

1846. 






Entered, according to Act of Congress, in the year one 

tiiousand eight hundred and forty-six, by 

BARRINGTON & HASWELL, 

in the clerk's office of the District Court for the Eastern District 

of Pennsylvania. 



i 






PREFACE 

TO THE SECOND EDITION. 



In the publication of the first edition of this volume, 
unforeseen circumstances so limited its size and cha- 
racter, as to cause a considerable modification of the 
plan originally proposed : thus rendering it evidently 
incomplete, in the portion mainly connected with the 
title selected. Notwithstanding this, the work has 
gained for itself some little share of public favor, and 
drawn attention to a practical class of duties in which 
Professional Instruction was certainly deficient in this 
country, although Europe had long shown a different 
estimate of its importance. On the completion, there- 
fore, of the former edition, the author determined so 
to arrange the present one as to remedy these defects; 
and he has now, in addition to a careful revision and 
modification of the former text, added upwards of one 
hundred pages of new matter. The liberality of the 
publishers has also enabled him to increase very ma- 
terially the illustrations. These, it is hoped, will in- 
crease the usefulness of the volume, without adding 
much to its original cost. The execution of the cuts 
w^as confided to Mr. Spittall, and has been faithfully 
executed by him. 

Pretendingto offer nothing but " Hints on theEvery- 
Day Duties of the Surgeon," the consideration of 
many of the subjects referred to has necessarily been 
brief; and what might, perhaps, be looked on as 
oversights, become therefore part of the proposed 
structure. 

Aware, that in a subject of daily utility, little 
could be claimed as original, his wish has been rather 
to present what he knew from experience to be useful, 
than to suggest new methods or offer a collection of 



4 PREFACE. 

plans, plausible enough in theory, yet utterly defec- 
tive in practice. Nevertheless, he has not been 
inattentive to the onward progress of Surgery, even 
in these minor matters, and wherever new suggestions 
have seemed to be of value has embodied them in 
the text. In doing this, and throughout the work, 
he is consequently largely indebted to the practical 
men of both Europe and the United States ; and as it 
has not been an easy matter to define at the moment 
the source of information which, from its value, he 
had rendered matter of every-day practice, he has sub- 
joined a list of the authors whom he has mainly con- 
sulted, and to whom he would refer those who may 
wish to learn more in detail of the hints here given. 
From this reference, the younger reader will be 
enabled to trace the latest points from which the 
subject has been enriched : whilst the more advanced 
will readily recognise its Hippocratic origin beneath 
the more superficial stratum of the modern schools. 



HENRY H. SMITH. 



No. 117 S. Ninth Street, 
Oct. 1st, 1846. 



LIST OF AUTHORS. 



The following list embraces some of the more important 
works consulted in connection with the present subject : — 

Amesbury, on Fractures. 

J. Rhea Barton, North American Journal, &.c. 

BoYER, Maladies Chirurgicales. 

BouRGERY, Minor Surgery, by Kissam. 

Bond, North American Medical Journal. 

Baynton, on Ulcers. 

Sir Astley Cooper, on Dislocations and Fractures. 

Samuel Cooper, Dictionary. 

Coster, Manual of Operative Surgery, by Fife. 

Cutler, on Bandages. 

R. Coates, Journal Medical Sciences. 

Dorsey, Elements of Surgery. 

Dessault's Surgery, by Caldwell. 

Druit, Modern Surgery, by Flint. 

Dupuytren, Legons Orales. 

Fergusson, Surgery, by Norris. 

Gerdy, Bandages et Pansements. 

Gibson, Institutes and Practice of Surgery. 

Goddard, on the Teeth. 

Jamain, Petite Chirurgie. 

Liston, Elements of Surgery, by Gross. 

Mayor, Bandages et Appareils. 

Malgaigne, Medecine Operative. 

Pancoast, Operative Surgery. 

Pott, Chirurgical Works. 

Sedillot, Medecine Operatoire. 

N. R. Smith, Baltimore Medical and Surgical Journal. 

Thillaye, Traite des Bandages. 

Velpeau, Medecine Operatoire. 



CONTENTS. 



Preface to Second Edition 



PAGE 

3 



PART I. 



OF DRESSINGS AND BANDAGES. 



Introduction . . 


. 




. 


17 


CHAPTER I. 








ON THE PREPARATION AND APPLICATION OF DRESSINGS. 




Dressings, Preparation and Application of 


. 




19 


Apparatus for 








19 


Instruments of 


, 






19 


Pieces of 








22 


Lint 


, 






22 


Charpie 








23 


Cotton • • 


, 






26 


Tow 








27 


Compresses 


. 






27 


Square 








27 


Triangular 


, 






28 


Cribriform . 








28 


Perforated Compress 


, 






30 


Graduated . 








30 


Pyramidal 


, 






31 


Malteese Cross 








28 


Retractors 


, 






29 


Adhesive Strips 








31 


Baynton's use of 


. 






33 


applied in Epididy 


mitis 




, 


36 


Isinglass Plaster . 


, 






37 


Court Plaster 








38 


Poultices 


, 






38 


Plasters 








40 


Irrigation 


, 






41 


Rules for Dressing . 




• 


45 


CHAPTER II. 








OF THE PREPARATION AND APPLICATION OF THE 


BANDAGE. 




Bandaging .... 


, 


• 


48 


Roller, Simple 


, 


, 


48 


Manufacture of 


, 


, 


49 


Single-headed • 


• 


, 


49 


Double-headed . 


. 




. 


50 



CONTENTS. 



Bandage, rolling of . 
Application of 
Circular 
Oblique 
Spiral 
Uniting 
Dividing 
Compressing 
Expelling . 
Retaining 
Reverses of . 
Spiral . 
of Chest 

Abdomen 

Penis . 

Finger 

all the Fingers, or Gauntlet 

Demi-Gauntlet 

Upper Extremity- 
Lower Extremity 
French Spiral 

CHAPTER III. 

OF THE CROSSED, OR FIGURE OF 8 BANDAGES 

Crossed of one Eye 
both Eyes 
Angle of the Jaw 
the Jaw- 
Barton's for the Jaw 
Posterior 8 of the Chest 
Anterior 8 . 
Of one Breast 

both Breasts 
Spica of Groin . 

both Groins 
Shoulder 
Thumb 
Instep 
Figure of 8 of the Elbow 
Wrist 
Figure of 8 of both Thighs 
Knee 
Ankle 
Figure of 8 of Neck and Axilla 
Ribbail's 

CHAPTER IV. 

OF KNOTTED BANDAGES. 

Knotted Bandage of Head 



89 



CONTENTS. 



CHAPTER V. 

OF RECURRENT BANDAGES. 

Recurrent Bandage of Head 

two Globes . 
Amputations 

CHAPTER VI. 



91 
92 
93 



OF THE COMPOSITION AND APPLICATION OF THE COMPOUND 
BANDAGE, OR THE BANDAGE PROPER. 



T Bandage 



i . . . • 


. 95 


of Head . . . 


96 


Ear 


. 97 


Nose .... 


98 


Chest 


. 99 


Abdomen 


99 


Triangular T of Groin 


. 100 


Double T of Buttock 


101 


of Hand 


. 102 


Perforated of Hand 


102 



CHAPTER Vn. 

OP THE INVAGINATED, OR SLIT AND TAIL BANDAGES. 

Invaginated Bandages . . . . 104 

for Wounds of Lips . , . 104 

of Body . . . . . 105 

for Longitudinal Wounds of the Extremities 106 
for Transverse Wounds of the Extremities 107 
for Wry Neck . . . 107 

Jbrg's Apparatus . . . . .108 

Uniting, of Transverse Wounds of Neck . , 110 



CHAPTER VHI. 

OF SLINGS. 



Slings 



or Bandage of Galen 

Four-tailed of Head 

of Neck ..... 

of Chin 

of Face ... 

Mask ..... 

of Breast . 

CHAPTER IX. 

OF SUSPENSORIES, SHEATHS, AND LACED BANDAGES 

Purses or Suspensories 

ofNose 

of Scrotum . . > 
Sheaths . . . ... 



Ill 
111 
112 
113 
113 
114 
114 
115 



117 
117 
118 
119 



10 



CONTENTS, 



Laced or Buckled Bandages 



Gaiter 
Stocking 



for the Knee 



PART II. 



119 
119 
120 
120 



CHAPTER I. 

MAYOR'S HANDKERCHIEF SYSTEM. 
General Considerations 

CHAPTER II. 

OF THE HANDKERCHIEFS AS APPLIED TO THE HEAD, 

Handkerchiefs for Head 

Square Cap of Head . 
Fronto-Occipital Triangle 
Occipito-Frontal 
Bi-Temporal Triangle 
Occulo-Occipital Triangle 
Fronto-Occipito-Labialis . 
Facial Triangle 
Verlico-Mental Cravat 
Occipito-Auricular 
Sternal Handkerchief 
Fronto-Dorsal 
Parieto-Axillaris 

CHAPTER HI. 

OF THE HANDKERCHIEFS AS APPLIED TO THE TRUNK 

Cervical Cravat ..... 
Simple Bis-Axillary Cravat . 
Compound Bis-Axillary Cravat . 
Simple Bis-Axillo-Scapulary Cravat . 
Compound Bis-Axillo-Scapulary Cravat 
Dorso-Bis-Axillaris . 
Triangular Cap of Breast 
Sub-Femoral Handkerchief . 
Inter-Femoral Handkerchief 
Single Spica Handkerchief . 
Double Spica Handkerchief 
Suspensory or Handkerchief to Scrotum 

CHAPTER IV. 

OP THE HANDKERCHIEFS OF THE UPPER EXTREMITIES. 

Cervico-Brachial Sling ..... 
Ante-Brachial Trough .... 

Triangular Cap of Shoulder .... 
Triangular Cap of Amputations . . . 



121 



128 
128 
128 
129 
130 
130 
130 
131 
131 
131 
132 
133 
138 



135 
135 
135 
136 
137 
137 
138 
139 
140 
140 
140 
141 



142 
142 
144 
144 



CONTENTS. 



11 



Carpo-Olecranien Handkerchief 
Flexor of Wrist 
Carpo-Dorsal Triangle . 



145 
145 
146 



CHAPTER V. 



OF THE HANDKERCHIEFS OF THE LOWER EXTREMITIES. 



Metatarso-Malleolar Cravat . 


, 




147 


Triangular Cap of Heel . 




. 


. 147 


Tarso-Pelvien Cravat . 


, 




148 


Compound Metatarso-Rotular Cravat 


. 148 


Tarso-Patella Cravat . 






150 


Triangular Cap of Foot . 




, 


. 150 


Tibio.Cervical Sling . 






150 


Tibial Cravat 




, 


. 152 


Barton's Handkerchief 






153 


Mayor's Hyponarthecia 




, 


. 153 


Anle-Brachial Hyponarthecia 






158 


Hyponarthecia of Lower Extremities . 




, 


. 160 


Mayor's Clinical Frame 






176 



PART III. 



CHAPTER I. 




APPARATUS FOR FRACTURES. 




General Considerations 


. 186 


CHAPTER II. 




FRACTURES OF BONES OF THE HEAD AND TRUNK 




Fractures of Skull .... 


. 1917 


Nose 


191 


Lower Jaw 


. 191 


Gibson's Bandage for 


192 


Vertebrae .... 


. 193 


Sternum .... 


193 


Ribs . . . • 


. 194 


Pelvis ..... 


194 


Clavicle .... 


1D4 


Dessault's Apparatus for . 


194 


Boyer's „ 


198 


Mayor's ,, 


199 


Fox's 


200 


Scapula .... 


202 


Velpeau's Bandage for - 


. 203 



12 



CONTENTS. 



CHAPTER III. 

OF FRACTURES OF THE UPPER EXTREMITY. 

Fractures, Neck of Humerus 

Boyer's Bandage for 

for Fracture of Shaft of Humerus 
Pennsylvania Hospital Plan 
of the Condyles 

Physick's Apparatus for 
Carved Splint . 

Fore-arm 

Lower End of Radius 

Barton's Bandage for 

Metacarpal Bones . . 

Phalanges . , 

Olecranon 

Astley Cooper's Apparatus for 
JDessault's „ 

Pennsylvania Hospital „ 
Boyer's „ 

Mayor's „ 

Gerdy's „ 

of Coronoid Process 

CHAPTER IV. 

OF FRACTURES OF THE LOWER EXTREMITY 

General Considerations .... 
Elevator for Treatment of 

CHAPTER V. 

OF FRACTURES OF THE FEMUR. 

Fractures, of Femur 

Bell's Inclined Plane 
Dupuytren's Inclined Plane 
Coates's Extending Band 
Physick's Gaiter 
Coates's Perineal Band . 
Junct-Bags . 
Splint Cloth 
Scultet's Bandage 
Eighteen-Tailed Bandage 
Splints, Dessault's . 

Physick's 

Boyer's 

Hartshorne's 

Amesbury's 

Gibson's Hagedorn 
Gibson's Simple Inclined Plane 
N. R. Smith's Splints , 



CONTENTS. 13 

CHAPTER VI. 

OF FRACTURES OF THE PATELLA. 

Fractures, of Patella . . . . .243 

Dessault's Apparatus for . . 243 

Dorsey's „ ... 244 

Mayor's „ . . 245 

Gerdy's „ ... 245 

CHAPTER Vn. 

OF FRACTURES OF THE LEG. 

Fractures, of Leg ..... 246 

Hospital Fracture-Box . . . 246 

Barton's Bran Dressing . . 248 

Amesbury's Apparatus for . . 249 

Dupuytren's Apparatus for Fracture of the 

Lower Extremity of the Fibula . 253 
Boyer's Apparatus for Fracture of the Os 

Calcis ... 254 

CHAPTER Vni. 

OF THE IMMOVABLE APPARATUS. 

General Account of . . . . • 256 



PART IV. 

CHAPTER I. 
OF THE APPARATUS FOR IHE TREATMENT OF DIS- 
LOCATIONS. 
General Considerations . . . . 263 

CHAPTER II. 

DISLOCATIONS OF THE HEAD AND TRUNK. 

Dislocations, of Head and Trunk . . . 265 

Lower Jaw .... 265 
Oblique Processes of Verlebree . 266 

Ribs . . . . .266 

Clavicle .... 267 

CHAPTER m. 

DISLOCATIONS OF THE UPPER EXTREMITY. 

Dislocations, of Upper Extremity . . . 269 

Head of Humerus . . . 269 

Fore-arm . * . .271 

Head of Radius . . . 272 



14 



CONTENTS. 



Dislocations, RedQction of . . . 

Rule for Diagnosis of Injuries to Elbow 
of Bones of Fore-arm on Wrist 
of all Bones of Wrist 
ofMagnum . , . 

of Metacarpal Bones . 
of Phalanges 



Clove Hitch 



273 
273 
274 
274 
274 
275 
275 
276 



CHAPTER IV. 



ON DISLOCATIONS OF THE LOWER EXTREMITY. 



Dislocations of Hip-Joint 


. 278 


Fahnestock's Mode of Reducing . 279 


Reduction by PuUies 


. 279 


Dislocation on Pubis . 


281 


into Sciatic Notch • 


. 281 


Foramen Thyroideum 


282 


of Patella . 


. 282 


Head of Tibia. 


283 


Fibula 


. 283 


Bones of Tarsus 


283 


Metatarsal Bones 


. 284 


Phalanges 


284 


PART V. 




OF THE MINOR SURGICAL OPERATIONS. 


Definition of . 


. 285 


CHAPTER I. 




OF BLOOD-LETTING 




Phlebotomy .... 


285 


Venesection .... 


. 286 


Anatomy of Veins of Arm . 


286 


Lancets .... 


. 289 


Spring Lancet 


289 


Thumb Lancet .... 


. 290 


Operation with Spring Lancet 


291 


Thumb Lancet . 


. 292 


Bleeding in Hand 


293 


External Jugular Vein 


. 293 


at the Ankle 


294 


Arteriotomy 


. 297 


Local Blood-letting . 


298 


Leeching 


. 299 


Arrest of Hemorrhage from 


301 


Preservation of Leeches . 


. 302 


Cupping . , . • 


303 



CONTENTS. 


15 


CHAPTER II. 




OP CUTANEOUS IRRITATION. 




General Considerations of . . . 


. 305 


Blisters ...... 


305 


Granville's Lotions for . 


. 307 


Issues . . . • 


307 


Issue Peas ..... 


. 308 


Formation of Issue by Potash, Acids, &c. . 


309 


Setons ...*.. 


. 310 


Moxa . . . . . . 


312 


CHAPTER III. 




OF PUNCTURES. 




General Considerations of . . . 


: 315 


Acupuncturation 


315 


Electro-Puncture . . . . 


. 317 


Vaccination 


317 


Preservation of Vaccine 


319 


Perforation of Lobe of Ear .... 


320 


Puncture of Membrana Tympani 


. 323 


Paracentesis Abdominis . . . • 


322 


Puncture of Hydrocele . . • . 


. 324 


Ranula ...... 


325 


Salivary Concretions . . • . 


. 326 


Puncture of Abscesses .... 


326 


Diagnosis of Abscesses .... 


. 327 


CHAPTER IV. 




OPERATIONS FOR ARRESTING HEMORRHAGE. 




General Consideration of . 


329 


Pressure . . . . . 


329 


Spanish Windlass ..... 


331 


Tourniquet of Petit . . . . . 


332 


Ligature . . , • . 


334 


Surgeon's Knot . . , 


335 


Sailor's Knot . . . 


335 


Torsion . . . . . . , 


336 


Plugging of Nostrils . . , 


337 


Arrest of Hemorrhage from Rectum 


339 


Hemorrhage from Bladder .... 


340 


CHAPTER V. 




OFWOUNDS. 




General Consideration of ... . 


341 


Sutures . . . • . , 


341 


Interrupted Suture 


341 


Continued Suture ..... 


343 



16 CONTENTS. 

Twisted or Hare-lip 344 

Quilled . . . . . . 345 

Dry 345 

CHAPTER VI. 

CATHETERISM. 

General Consideration of . . . . 347 

Catheterism of Urethra . . . .347 

Stomach .... 351 

Eustachian Tube . • • 353 

CHAPTER Vn. 

OF INJECTIONS. 

General Use of . . . • . 355 

Injection of Lachrymal Ducts . . . . 355 

Lungs ..... 356 

into Urethra ..... 357 

Vagina ..... 358 

Rectum ; . . . . 358 

CHAPTER VIIL 

OF EXTRACTION OF FOREIGN BODIES, &C. 

General Consideration of . . . . 360 

Extraction of Teeth . . . • .360 

Cilise 363 

Foreign Bodies from Eye-Ball . . 364 

Matter from Eye-lids . 365 

Bodies from Nostrils . . 365 

Ear . . 365 

Throat . . 366 

Dr. Bond's Forceps for 367 



Trachea 
Matter from Wounds 
Bodies from Rectum 
Urethra 
Corns . . 

Bunnions 
Toe Nail Ulcer . 

Dr. Meig's Plan of Treating 
Various Operations 
Insertion of Glass Eye 
Excision of Pterygium . 
Uvula 
Tonsils 



368 
368 
369 
369 
369 
371 
371 
372 
373 
373 
374 
375 
376 



Conclusion . . . . . . 377 



MINOR SURGERY. 



PART I 



INTRODUCTION. 

The daily duties required of the surgeon, call for 
such varied qualifications, both in his natural tem- 
perament and that acquired by education, that com- 
paratively few of the great mass of medical men, are 
fitted for their performance, or have any inclination 
to undertake them. All practitioners are, however, 
often compelled by circumstances to resort to means 
that are as purely operative, as those necessitating the 
extensive use of the knife, and Surgery has, there- 
fore, since a very early period, been divided into 
Minor and Major Surgery, or parts purely operative 
or otherwise ; the various works written on the subject, 
having thus divided their matter, in order to treat it 
the more systematically. But as these terms are 
purely conventional, there has been much difference 
of opinion, as to what constituted the boundaries of 
each, and some writers have in consequence, so min- 
gled the two, as to render it difficult to know where 
to draw the line. 

In the strictest acceptation of the term, Minor 
Surgery means that portion of Surgery, proper, which 
treats of the minor operations, such as Bleeding, 
Leeching, Extraction of Teeth, &c. This, however, 
is too limited a definition to meet the necessities of 
2 



18 INTRODUCTION. 

most practitioners, and in the present work, we shall, 
therefore, embrace a wider field, and include under 
the head of Minor Surgery, all such duties, as every 
medical man is liable to, provided they do not re- 
quire the extensive division of our tissues, or, in 
other words, constitute a capital operation. 

In the systematic consideration of our subject, five 
divisions, naturally present themselves : — 1st. Dres- 
sings and Bandaging, — 2d. Provisional Dressings,— 
3d. Apparatus for Fractures, — 4th. Apparatus for 
Dislocations ; and 5lh Minor Operations. 



APPLICATION OF DRESSINGS. 19 



CHAPTER I. 

ON THE PREPARATION AND APPLICATION OF 
DRESSINGS. 

Although very varied information and skill, are 
necessary to the immediate treatment of surgical in- 
juries, and especially those requiring the performance 
of operations, yet will the successlikely to follow them, 
depend in a great degree, upon the attention subsequent- 
ly given to the case. The art of Dressingbecomes, there- 
fore, a subject of equal, if not greater importance, than 
that of operating, and should be properly regarded as a 
matter of vital consequence, as without it all other means 
would often prove unavailing. The object of all dress- 
ings, being the relief of injured parts, their application 
must, of course, depend upon circumstances, but gene- 
rally, they are intendedto preserve such parts in proper 
coaptation ; to unite them, or prevent too hasty union ; 
to shelter them from the action of the atmosphere or 
of external injuries ; to absorb discharges ; prevent des- 
sication of surface ; and lastly, though equally im- 
portant, to ensure cleanliness. Dressings may, there- 
fore, be defined as those portions of different sub- 
stances, which are applied with such intentions, di- 
rectly to operated or injured surfaces. 

The different articles employed and the means by 
which they are appHed, are known under the general 
head of Apparatus of Dressing ; and consists of two 
parts, one containing the Instruments for Dressings 
the other the Pieces of Dressing to be employed. 

The Instruments for Dressing, are such as are 
generally found in the assemblage furnished by the 
cutlers, and known under the name of the Pocket 
Case. This contains Dressing or Ring Forceps ; 
Simple Forceps ; Scissors, both straight and curved ; 
Probes ; Directors ; Spatulee ; Bistouries ; Abscess- 



20 PREPARATION AND 

Lancets ; Porte Caustic ; Tenacula ; Straight and 
Curved Needles ; Ligatures ; and often such others, 
as the taste of the cutler or his interests may lead 
him to select. Under the same head should also 
be included, Razors, Basins, Sponges, Buckets, and 
all that is requisite for the preparing of a part for the 
application of the dressing, or the removal of ihe 
previous one. 

The DressingForceps, are employed for removing 
the different pieces of dressing ; not only in order to 
protect the fingers of the Surgeon from discharges 
that are often very irritating, but also on account of 
their seizing them with less risk of injuring surround- 
ing parts, especially by pressure. In cases of fistulae 
or sinuses, they are also often necessary, in order to 
cleanse the bottom of the sinus, or remove deep- 
seated portions of dressing, or other foreign matter. 

The Simple or Dissecting Forceps, may be fre- 
quently substituted for the Dressing Forceps, especially 
where minute portions of dressing — as ligatures, &c., 
are to be removed. They are, however, more frequently 
used for seizing such portions of integument, &c., as 
may require to be cut off by the knife or scissors. 

The Straight Scissors, are employed in dressing, 
for the ordinary purposes of scissors — but those 
which are curved, either on the side or front, are 
mainly employed in the removal of such dressings as 
adhere closely to the body; as adhesive strips, bandages, 
&c., especially where it is desirable to remove them 
without deranging the position of the part. Scissors 
are also occasionally used for excision of portions 
of integuments, as in hare-lip ; but they do not answer 
as well as the scalpel for such operations, because 
they are apt to bruise the edges of the part divided, 
and thus interfere with its subsequent adhesion. 

Probes, should always be made of silver, or some 
equally flexible metal, in order that they may be 
readily bent, to suit the position of the part to be 



APPLICATION OF DRESSINGS. 21 

examined. They are employed either for the exami- 
nation of parts deeply seated within the integuments, 
or for the introduction of different portions of dress- 
ings into fistulse, &c. 

The Director, is a broad probe with a groove in 
it, which is generally used to direct the point of a 
scalpel or bistoury, in the division of deep-seated 
parts, especially where important organs are in the 
neighbourhood of the incision. Sometimes it has 
a flat end for a handle, and sometimes a ring or some 
slight expansion, to keep it from turning in the 
fingers of the operator. 

The Spatula, may be used either in spreading 
cerates, in the preparation of dressings, &c., or for 
removing such portions of similar substances as re- 
main adherent to the skin. 

Bistouries and Scalpels, are required for various 
operations involving the division of the different tis- 
sues of the body. Their use, therefore, is generally 
described in the works on Operative Surgery. 

Abscess Lancets resemble the ordinary thumb- 
lancets, except that they are larger. The manner of 
using them will be again referred to. 

The Porte-Caustic is employed, as its name 
designates. It usually carries in it the Nitrate of 
Silver, or lunar caustic, and not the caustic potash. 
As a general rule it should be made of silver, as 
this metal is not acted upon by the caustic ; whereas 
bone and similar substances, of which it is sometimes 
formed, are soon destroyed. When it is desirable in 
arming it, to give the caustic a fine point, so as to enable 
us to touch only small spots, as in the treatment of ul- 
cerated cornea, chancre, &c., it will be best accomplish- 
ed by rubbing it down with a piece of wet rag, so as to 
wear it away, rather than by scraping ; as the brittleness 
of the nitrate of silver, renders it difficult to bring it 
to a point, merely by the use of the knife. 

Straight and Curved Needles — Tenacula 



22 



PREPARATION AND 



and Ligatures, will be treated of under another head, 
and the other instruments of dressing are so simple, 
as only to require the mere mention of them, in 
order to guard against their omission in the Apparatus 
of Dressing. 

The Pieces of Dressing, are Lint ; Charpie ; Cot- 
ton ; Tow ; Spread Cerate, or other ointment ; Com- 
presses ; Malteese Cross ; Shields for Amputations ; 
Adhesive Strips ; Setons ; Poultices ; Plasters ; and 
means of Irrigation. 

Lint, is a soft, delicate tissue or mass, prepared in 
two ways ; — in one of which the transverse threads 
of soft old linen, are drawn out by a machine, leaving 
the longitudinal ones covered by a sort of tomentum 

Fig. 1. 




or cotton-like mass ; the other, in which the cotton- 
like surface is produced by scraping with a sharp 
knife, a similar piece of cloth, previously fastened 
to some firm substance. The first is known as the 
Patent Lint, and may be obtained of any druggist. 



APPLICATION OF DRESSINGS. 23 

as it is now generally manufactured. The second, is 
the Domestic Lint, and may be made at a moment's 
notice when the first is not convenient. They are 
both employed as primary dressings, either spread 
with ointments, or alone. 

Charpie, is a substance much employed by the 
French surgeons, and now gaining a more general 
application in the United States. It is made by 
collecting the threads torn from pieces of linen, four 
or five inches square, such as is used for patent lint. 
The process, however, goes a step farther than that 
for making lint, and tears the threads entirely apart, in- 
stead ofpreserving the cloth. The cloth should be new 
and clean ; especially as Gerdy has proved, that when 
made from new linen, it absorbs better than when old. 
It is usually divided into two kinds, according to the 
length and fineness of the thread composingit; that which 
is long and coarse beingemployed to keep open sinuses, 
fistulae, and as an outer dressing; while the softer, finer 
kind may be placed in immediate contact with the 
part, especially where the surface requires stimulation. 

Various names are given to Charpie, according to 
the way in which its fibres are arranged, previously 
to its application. Thus there is the Pledget, Roll, 
Tent, Mesh, Bullet, Tampon, and Pellet; each of 
which have their peculiar advantages. 

The Pledget, is a mass of charpie i-v^. 2. 

formed by a collection of ravellings, 
the threads of which are laid parallel 
to each other, with the ends folded 
underneath. This being flattened 
between the palms of the hands, may 
be made of an oval, spheroidal, or 
square shape, according to the part 
on which it is to be applied. As 
thus formed, it is usually spread with 
cerate, and neatly adapted to the 
parts it is to cover ; care being taken not to make it 




24 



PREPARATION AND 



Fig. 3. 




SO thick as to overload and heat it, nor yet so 
thin as to become quickly saturated with the pus. 
Where charpie cannot be obtained, the patent lint, 
cotton, or tow, similarly arranged, may be substituted. 
The Roll, is a smaller mass of charpie, 
formed by rolling its fibres longitudinally 
between the hands, so as to make an ob- 
long mass, which is then tied firmly in the 
middle, so that when the ends are brought 
in contact laterally, it may form a sort of 
cone. It serves for absorbing pus in deep 
wounds, where there is a tendency in the 
edges to close, before the bottom has filled 
up. It is also useful in arresting hemor- 
rhages from deep-seated vessels ; pressure 
being made by forcing the central part 
upon the vessel by a probe, while the 
loose tissue made by the ends, assists in the formation 
of the clot. A director or probe is necessary, in order 
to carry it into deep wounds or upon a vessel. 

The Tent, is a conical or cylindrical mass of charpie, 
formed like the roll, except that 
instead of applyingastringtoits 
middle, it is there simply dou- 
bled on itself and its loose ends 
twisted by the fingers, so as to 
give it a spiral form and make 
the apex of a cone, the base of 
w^hich is the part where the fibres are doubled on 
themselves. This, is also employed to dilate fistulous 
canals, or openings which are too small to allow of the 
free escape of pus, and where only moderate dilatation 
is required. But where parts are rigid, the Sponge Tent, 
or that made by slicing gentian, carrot, or some other por- 
ous root into the shape of a cone, or plug, answers better. 
The Sponge Tent, is the one most generally em- 
ployed, and answers better than the others in most 
cases. It is prepared by saturating common sponge 



Fig. 4. 




APPLICATION OF DRESSINGS. 



25 



Fig. 5. 




with melted bees-wax ; allowing it to cool and 
harden ; and then slicing it into small pieces, of 
such a size as will nearly fill the orifice to be di- 
lated. The heat of the part melts the wax ; the 
sponge fills with the fluids of the tissues, 
and gradually dilates them to the size 
required ; after which a new morsel must 
be introduced. 

The Mesh, consists of the threads of 
charpie, placed parallel with each other 
andbent on themselves, and is of great use 
in the treatment of deep fistula, espe- 
cially fistula in ano. When thus used, 
it should be anointed with cerate, and 
introduced into the cavity on the point 
of a probe until it touches the bottom. 
It acts by preventing the edges from 
healing, and causing the cavity to fill 
from below, upwards. 

Bullets, are little balls, made by rolling charpie 
between the hands until it 
acquires this form. They are 
extremely porous, absorbent, 
and useful in filling up puru- 
lent cavities ; where they pre- 
vent the matter from bur- 
rowing. 

When a number of Bullets _ 

are placed together at the 

bottom of any cavity, either with a view of distending 
it, or of arresting hemorrhage, they take the name of 
Tampon. They are often thus used in gonorrhoeal 
inflammations of the vagina ; in fluor albus ; and to 
arrest uterine hemorrhage. For the latter purpose, 
especially if the hemorrhage follows an operation, or 
a laceration of the neck of the womb, they may be 
made of the Boletus Igniarius, or puff-ball. 

The Pellet, is a large bullet surrounded by a piece 





26 PREPARATION AND 

of soft rag, the edges of which are brought together 
and tied firmly. It is occasionally em- 
^^S"- '^' ployed in the treatment of hernia, espe- 
cially the umbilical hernia of children, 
where, when bound down by adhesive 
strips, or a bandage, it answers very well 
the purpose of a truss. It is also useful 
in the compression of large vessels ; as in 
wounds of the axillary artery, in the reduction of 
dislocations into the axilla, and in hemorrhage from 
parts in the neighbourhood of the rectum, being there 
confined under a T bandage. 

In the hemorrhage which sometimes follows the ex- 
traction of a tooth, a very useful pellet may be formed 
of a bottle cork, cut into a cone and forced into the 
socket with a little lint, by closing the jaws. 

For the convenience of those who may desire to 
obtain charpie in this country, I would state that 
Mrs. F. B. Jones, S. W. corner of Juniper and Walnut 
Streets, Phila.,makesit of an excellen,t quality, at $1.25 
per pound ; very little more than the cost of patent lint. 
Cotton and Tow, are substances which are too 
well known to require a description. Both are of 
comparatively limited utility as dressings, their places 
being usually supplied by charpie. Before, however, 
the application of either to surgical purposes, they 
should be well picked or carded, to free them from 
foreign matter. The chief use of cotton, is as a dress- 
ing to superficial burns, where it is useful by pro- 
tecting them from the air, absorbing the discharges, 
and thus forming a sort of scab under which tney 
readily heal. When intended to be thus used, it is, 
however, especially necessary to see that it is free 
even from specks^ as the fly is exceedingly apt to lay 
its egg in it, where, being vivified by the heat of the 
body, it generates maggots, to the great annoyance 
of the patient and the astonishment of all around him ; 
who, under the belief that he is eaten by worms, 
usually regard it as a fatal sign. 



APPLICATION OF DRESSINGS. 



27 



Tow, is employed chiefly as an outer dressing, to 
stumps which are discharging freely, in order to 
protect the bed. Care is requisite in forming the 
Pledget of Tow for this purpose, that it be not too 
thick and heating, as union, is often thus prevented. 
Compresses, are pieces of linen of various sizes, 
used to make pressure, confine dressings, prevent 
external injuries, and equalise the surface of limbs, in 
order better to adapt them to the use of the bandage, 
and the compression of the soft parts. They may be 
made of any soft substance, as flannel, muslin, calico, 
&c., and with one or two exceptions, are to be applied 
over other dressings. When intended to be placed 
directly on a wound, they should always be made of 
soft linen, or lint. 

Compressess have received various 
names, according to the way in which 
they are folded, or the indications to be 
fulfilled ; thus we have the Square, Ob- 
long, Triangular, and Cribriform Com- 
press, the Malteese Cross, the Half 
Malteese Cross, the Single and Double 
Split Compress, as well as the Perforated, 
Graduated, and Pyramidal Compresses. 
The Square Compress, is that in 
which the substance used has the same 
dimensions in its two principal diame- 
ters. If it is twice as long as it is 

broad, and will form a square when doubled in its 

length, it constitutes the Oblong 

Compress, or Band, and is useful 

in surrounding the trunk, or 

limbs. If it is a square piece 

of linen folded so as to unite 

two of its angles, it forms the 

Triangular Compre.ss. This is 

exceedingly useful in confining 

dressings to stumps, especially 

when it is desirable to remove the dressing frequently 





28 



PREPARATION AND 



t > \ k » « « < • 

,««»»* f f t 

» « V « « « c * « 

HI •«>*«*» 
I « •«»»«»« 
»♦♦»««» I » 
« 4 « « > 1 » « « 
t « ^ i « ( t f 4 
f » ♦ « ♦ » » » 



without deranging the limb, as in the use of poultices, 
&c. To apply one for this purpose, cut it of such a 
size as will surround the limb, place the stump in the 
centre of the side a 6; then turn up the apex c, and 
afterwards the points aandZ>; confining them by pins. 
The Cribriform Compress, is a square piece of linen 
in which a number of holes are cut. It is formed by 
folding linen four or six times on 
^^^' ^0- itself, so as to form several ob- 

long squares, one within the 
other; then nick the sides in 
several points with the scissors, 
soastoremovesmallpieces; and 
on opening it out, we shall have 
the form desired. When spread 
with cerate, it is to be applied 
directly to a suppurating sur- 
face, and the pus, passing out 
through the holes, will allow the compress to remain 
directly in contact with the surface, and thus pre- 
vent the wound from being constantly bathed in mat- 
ter, which sometimes is unhealthy. It will also assist 
in the removal of other dressings, by preventing them 
from sticking to the part. 

The Malteese Cross, so named from 
its shape, is made from a square piece 
of linen, by folding it into an oblong 
square ; doubling this in its length to 
form a smaller square ; joining two 
of the angles to form a triangle, as in the 
figure ;(Fig. ll)andfoldingthis equila- 
terally, to form a smaller triangle ; then 
mark a line on its hypotheneuse half 
an inch from its apex, and slit the sides 
down to this line, as in that which is dot- 
ted in the figure. On opening it out, we have a very regu- 
lar cross, with a space in the centre, (Fig. 12), intended 
to cover the front of the stump, whilst the arxgles go 




APPLICATION OF DRESSINGS. 



29 



Fig. 12, 




jP/g, 13. 




around it. This cross is of great use, as a primary or 
secondary dressing in 
amputations, as by means 
of the slits, it folds over 
and fits the part, very ac- 
curately. 

The Half Malteese 
Cross (Fig. 13) is formed 
by slitting the two angles of 
the loose side of an oblong 
square, to within an inch or 
two of their centre, as seen 
in the figure, and in some 
cases serves a better pur- 
pose than the full cross ; 
as in dressing stumps at 
the shoulder, or after am- 
putation at the hip-joint, 
&c. If the linen is doubled and cut 
in this form, it will, when opened out, 
form the cross (Fig. 12) as readily, as 
the one in the plan there stated. 

The Retractor of Two Tails, (Fig. 
14) is an oblong piece of muslin split as 
represented in the figure, and intended 
to be used as a shield to the soft parts, 
in amputations of the arm or thigh. In 
applying it, draw the tails downwards 
on each side of the bone, and the 
upper part or body of the retractor, 
upwards over the stump, so as to 
force back the muscles and protect 
them from the action of the saw. 
The diamond shaped opening at the 
end of the split, is intended to adapt 
it more accurately to the bone it- 
self. 



Fig. 14. 



The Retractor of Three Tails, (Fig. 15) is made 



30 



PREPARATION AND 



like the preceding, only it is split into three tails in- 



Fig. 15. 



0^ 



stead of two. It is employed in the 
same manner, in amputations of the 
forearm and leg ; the third or middle 
tail, being pushed through the inter- 
osseous space, so as to protect more 
thoroughly both the bones of the part. 
The Perforated Compress, (Fig. 
16) is the name given to a piece of 
muslin folded several times on itself, 
so as to make a thick mass, in the 
centre of which an opening is cut. It 
is used in order to relieve points from 
pressure, especially where they have a 
tendency to slough, as on the internal 
condyle in fractures of the arm ; on 
the trochanter of the femur, or on 
the heel, in fractures of the lower 
extremity. The sore point, being 
placed in the centre of the opening, 
is saved from the weight, whilst the 
pressure is borne by the parts on its circumference. 
Frequently it is made out of a small pad 
or pillow, cut and formed like Fig. 16. 
Whenever used, attention should be paid to 
the parts of the limb, pressed on by the cir- 
cumference of the opening. 

Graduated Compresses, are named from 
their construction, and are of several kinds ; 
the substance of each being folded differ- 
ently, according to the object in view. 

The Common Graduated 
Compress, is made by fold- 
ing a piece of muslin several 
times on itself, so that each 
fold may not entirely cover 
the one that has preceded it. 
It may be graduated at one end, as in the cut, or 



Fig. 16. 




Fig.V 


r. 







APPLICATION OF DRESSINGS. 



31 



Fi!r. 18. 





from end to end as would be the case if Fig. 17 had 
another folded end at its left extremity. 

The Pyramidal Compress, is 
one that is most accurately form- 
ed, by placing on one another 
squarepieces of muslin, gradually 
decreasing in size, so as to form 
a pyramid (Fig. I8j. It may 
also be made by folding a piece 
of 2^ inch bandage on itself, so 
as to form a compress graduated 
from end to end, and then placing 
a piece of cork, or cotton, or other body in the centre 
of the last turns (Fig. 19.) 
Thus formed, it is very ^^S"- ^^' 

useful in making pressure 
upon certain points ; as in 
cases of hemorrhage from 
the deep-seated vessels of 
the leg, or arm. 

Adhesive Strips, are pieces of linen spread with 
some adhesive plaster, (usually Diachylon,) and in- 
tended to promote the union of divided parts. As this 
plaster is kept very generally by the druggists, the for- 
mula for its composition, would here be out of place. 
When the strips are wanted, they may be prepared from 
the sheet on which it is usually spread, by sliding the 
scissors according to the line of the thread of the 
cloth, and slitting it into pieces about three-quarters 
of an inch in width, (Fig. 20) and of a length suffi- 
cient to enable it to extend at least three inches be- 
yond each side of the wound which is to be united. 
Before applying them, it is generally necessary to 
soften the plaster by heat ; and the most convenient 
method of so doing, is to fill a bottle with boiling 
water and wrap the strip around it ; the outside of 
the strip being next the surface of the bottle. In its 
application, the strip should be first placed on that 



32 



PREPARATION AND 



portion of the wounded surface which is most de- 
pending, in order to draw it up to the other, and not 
from above downwards ; the intervals between the 
strips being such as to allow of the free escape of 
matter. In order to remove them readily, wash the 
part with warm water, or apply a warm poultice to 
it a few hours before the dressing is to be changed. 
After this, the surgeon lays hold of one of the extre- 
mities of each piece in succession, and gently raising 




its end, reflects it upon the wound. This extremity 
being detached to within half an inch of the edge, 
he detaches the other to about the same distance, 
and holding them together, lifts them perpendicularly 
from the parts, taking care at the same time to apply 



APPLICATION OF DRESSINGS. 



33 



the thumb and index finger of the left hand upon the 
sides of the wound, to prevent injury being clone to 
the cicatrix. (Fig. 21.) 

Fig. 21. 




As adhesive strips sometimes irritate and inflame 
the skin, owirg to their tearing out the small hairs 
or down, which cover it, or to the plaster being badly 
made, their application is frequently followed by 
Erysipelas. In this case, their place may be very 
well supplied by the slit and tail, or uniting bandage 
hereafter mentioned, or by Cooper's Isinglass Plaster. 
Adhesive strips are also much used as a dressing to 
ulcers ; for compression in cases of Epididymitis or 
Hernia Huraoralis, &c., &c. 

As the treatment of ulcers by means of these adhe- 
sive strips has gained much celebrity, a detailed ac- 
count of Baynton's plan is here given. 

*' The parts," says Mr. Baynton, " should be first 
cleared of the hair sometimes found on them in con- 
siderable quantities, by means of a razor, that none 
of the discharges by being retained may become 
acrid and inflame the skin, and that the dressings 
may be removed with ease at each time of their re- 
newal, which in some cases where the discharges are 
very profuse, and the ulcers irritable, may perhaps 
be necessary, twice, in twenty-four hours. Several 
3 



34 PREPARATION AND 

strips of adhesive plaster, about two inches in breadth, 
and of a length that will, after being passed round 
the limb, leave an end of about four or five inches, 
are to be applied to the sound part of the limb, the mid- 
dle of the strap being opposite to the inferior portion 
of the ulcer, so that the lower edge of the plaster may 
be placed about an inch below the lower edge of the 
sore, and the ends drawn over the ulcer with as much 
gradual extension, as the patient can well bear. Other 
slips are to be secured in the same way, each above, 
and in contact with the other until the whole surface 
of the sore and the limb are completely covered, at 
least one inch below, and two or three above the 
diseased part. 

'' The whole of the leg, should then be equally de- 
fended with pieces of soft calico, three or four times 
doubled, and a bandage of the same, about three 
inches in breadth, and four or five yards in length, or 
rather, as much as will be sufficient to support the 
limb from the toes to the knee, should be applied as 
smoothly as possible, and with as much firmness as 
can be borne by the patient. 

'' If the parts be much inflamed, or the discharges 
very profuse, they should be well moistened and kept 
cool with cold spring water, poured on them as often 
as the heat may indicate to be necessary, or perhaps, 
at least once in every hour. The patient may like- 
wise take what exercise he pleases, and it will be 
always found that an alleviation of his pain, and the 
promotion of his cure, will follow as its consequence, 
though under other modes of treating the disease, it 
aggravates the pain, and prevents the cure. The 
first application will sometimes occasion pain, which, 
however, soon subsides, and is felt less sensibly at 
every succeeding dressing. The force with which 
the ends are drawn over the limb, must then be 
gradually increased until the parts are restored to their 
natural state, especially if the limb be in that enlarged 



APPLICATION OF DRESSINGS- 35 

and incompressible state which has been denominated 
the scorbutic. 

Fig. 22. 




*' If the patient be of a spare habit, it may be 
necessary to guard against excoriation by defending 
the tendo-Achilles with a small shred of soft leather, 
previously to the application of the adhesive slips. "^ 

This plan, although published by Mr. Baynton in 
1797, has yet many opponents among the English 
surgeons, who deny entirely its utility, or insist 
that it can be replaced by better and less trouble- 
some means, such as bandages, &c. But the expe- 
riments of Velpeau, Roux, and many others of the 
French surgeons, have established very conclu- 
sively, that it requires only about half the time to 
cure an ulcer under Baynton's plan, than it did under 
the old system of ointments, &c. Velpeau has also 
enlarged considerably the use of adhesive strips, on 
the principle of Baynton, as a means of making pres- 
sure, in the treatment of other surgical diseases besides 
ulcers, such as chronic enlargements of the joints ; in 
wounds in which it is difficult or improper to heal 
by the contact of the edges, on account of deformed 
cicatrises ; in the treatment of burns ; in ganglia, or 
other tumors about joints ; in scrofulous ulcers of the 
neck, especially when presenting thickened edges or 
those which are undermined ; and in different ulcers 
of the mammary region where otherwise cicatrisation 
would be extremely slow. '* In Burns," says he, 
"the adhesive strips act marvellously well. In those 
of the first degree, one application of the strips, sus- 



36 



PREPARATION AND 



tained slightly by a compressing bandage, and which 
may all be removed from the fourth to the eighth 
day, is sufficient to effect a cure. If it is a burn of 
the second degree, that is, one with blisters, and not 
much phlegmonous inflammation, I remove the cuti- 
cle, cleanse the exuded matter, apply the strips and 
obtain a cure at the end of the second dressing, 
sometimes at the first, and nearly alw^ays at the third; 
so that if it isnot cured by the fourth, it will be better 
to change the treatment. If there is much engorge- 
ment, with a tendency to erysipelas, I commence by 
an emollient poultice, or a few leeches, and then 
apply the strips. If the burn is of the third degree, 
that is to say, with change of structure, or conversion 
of the true skin to an eschar, the same treatment is 
pursued, and the cure is not less certain ; only it 
exacts here, ten or twenty days. When the burn is 
yet deeper and comprises the whole thickness of the 
derm, as the strips cannot do away with the neces- 
sary loss of substance in the separation of the eschar, 
it is useless to apply them before 
it has separated, that is, after the 
formation of the ulcer." 

It must, however, be recollected 
that Velpeau changes the strips 
every three or four days, and not 
every twenty-four or forty-eight 
hours, as proposed by Baynton. 

Nothing answers so well for a 
compressive bandage of the testi- 
cle in cases of Epididymitis, or 
chronic enlargement of the testicle, 
especially after free leeching, as a 
firm compression of the part by strips 
of adhesive plaster, as practised by 
Ricord and Fricke. In order to 
apply them in this case, the swelled 
testicle should be forced to the bottom of the scrotum, 



Fi^. 23. 




APPLICATION OF DRESSINGS. 37 

by surrounding the cord with the thumb and fingers of 
one hand so as to form a ring,while with the other, 
or with the hand of an assistant, the strips are so 
applied as to surround the part entirely as seen in 
Fig. 23. These strips should be of the width of the 
thumb, and applied over one another from below 
upwards, till the testis and a part of the cord are 
compressed between them. Previous to their appli- 
cation, the parts should be cleansed and well shaved; 
and the strips should be renewed, as often as they 
become slack from the abatement of the swelling in 
the testicle. 

It may perhaps be useful to the young surgeon to 
say, that the use of adhesive strips to suppurating sur- 
faces often produces a marked blackness of the skin. 
This is nothing but a chemical change, produced in 
the plaster by the action of the discharges, and not 
the forerunner of gangrene, as many have at first sup- 
posed. 

Considerable objection has been raised within the 
last few years, to the use of adhesive strips, as a 
means for uniting wounds, on the ground that it 
proved irritating, and gave rise to erythema and 
erysipelas. As a substitute for it, the Isinglass 'plas- 
ter has been verj generally recommended, as possess- 
ing equal adhesiv^e powers, and having the advan- 
tage, on account of its transparency, of enabling the 
surgeon to see the state of the wound through the 
plaster. 

'' It is composed," according to Mr. Liston, "of 
a solution of isinglass i^ spirit, and may be spread 
for use, as occasion requires, on slips of oiled silk ; 
on silk glazed on one side only, and on the unglazed 
side. It is cut into strips of the desired breadth, and 
the adhesive matter dissol^^ed immediately before 
it is employed, by the application of a hot, moist 
spo;ige." This plaster has been recommended to 
some extent in the United States, but our own expe- 



38 PREPARATION AND 

rience is against it, the warmth of the part, and the 
discharges, having invariably softened the material, 
as much as the sponge did previous to its application ; 
in consequence of which it invariably lost its hold. 

Court Plaster, sometimes called gummed silk, is 
occasionally used in slight wounds and excoriations, 
although mainly, in domestic practice. The English 
court plaster, that is generally deemed the best, is 
made by placing one part of choice isinglass, cut into 
little pieces, in an earthenware vessel upon a sand bath, 
and digesting it in four parts of water. When this 
is dissolved, it is strained through a fine linen cloth ; 
eight parts of alcohol are added ; it is evaporated to 
one-half, again strained, and the tepid liquid is then 
spread upon black silk with a camel's hair pencil. 
Four or five layers are thus put on, care being taken 
to see that the former is perfectly dry. Between the 
last two coats of the Icthyocolla, a little Tinct. of 
Benzoin or Bals. Peru is added to give it an agree- 
able flavour. Thus prepared, the plaster is allowed 
to dry for twenty-four hours. When used, a piece is 
moistened, by placing the gummed side on the tongue 
and immediately applying it."* 

Poultices or Cataplasms, are different kinds of 
pulp or pastes, intended to cover injured surfaces, 
and made of various substances, according as the 
object is to have an emollient, an astringent, or a 
stimulating one. 

The Emollient Poultice, may be made of any 
mild, unirritating substance, as bread and milk ; 
bread and water ; bran and water ; corn-meal and 
water ; and ground flaxseed, or flaxseed meal. The 
latter forms decidedly the best poultice, not only as 
regards its properties, but also its economy. It is 
prepared by simply pouring hot water on the meal, 

* BOURGERT. 

An analogous preparation will be fouud in the U.S. Dispensatory. 



APPLICATION OF DRESSINGS. 



39 



Fig. 24. 









^^ 


^^i 




W-'i'-' '' 


- ,,>^^l 




fe^;^ ■ 


,3^ 




S:S*?i^-VV'' < 


■'j ^ '""i j^h! 




H 


M^ 









and stirring it till it acquires such a consistence as 
will prevent its running from its softness, or its dry- 
ing and breaking off from the reverse. In order to 
spread it, a portion of the paste is dropped on a suit- 
able piece of muslin, and levelled of an even thick- 
ness, say about one-fourth or half an inch ; the free 
ends of the muslin being folded over, so as to form a 
sort of frame or border, and thus prevent the adhe- 
sion of the edges (Fig. 24). If 
the meal is not fresh, it will be 
necessary to rub a little sweet 
oil or lard over the surface of 
the poultice, or to cover it with 
a piece of fine gauze previously 
softened in warm water, to re- 
move its starch. This will pre- 
vent the adhesion of the poul- 
tice (Fig. 25). 

Every poultice should be 
renewed at least twice in twenty-four hours, or more 
frequently if it becomes hard 
and dry. Care must also be 
taken that the meal has not fer- 
mented, or the oil, if used, be- 
come rancid, as it will then 
irritate, instead of soothing the 
part. The bread and milk, or 
bread and water poultice, is 
made by breaking the crumb of 
bread into either of these liquids 
till they have the proper con- 
sistence, when they may be spread and used like the 
first one. 

The Astringent Poultice, is formed of the above, 
by adding some astringent article. Frequently it 
consists of bread and lead-water, or of a curd made 
by throwing alum into boiling milk and straining off 
the whey, or rubbing it up with the white of ^g^^. 



Fig. 25. 




40 PREPARATION AND 

These poultices should always be covered with gauze, 
being chiefly used in the treatment of affections of the 
eye. The oak bark, pomegranate, persimmon, nut- 
galls, bistort, tormentilla, &c., are also sometimes 
employed, beaten into a pulp, or mixed w^ith other 
and more adhesive or farinaceous substances. They 
may be used in any proportions. 

The Stimulating Poultice, is formed of various 
substances, as boiled carrot, grated down to a pulp ; 
raw potato, grated and applied cold ; grated onions, 
grated horse-radish, cloves of garlic, or black 
pepper ; corn-meal and some fermenting liquor, as 
yeast or porter ; or flowers of mustard. 

The Fermenting Poultice, or that made of corn- 
meal and porter, should always be spread on or covered 
with oiled silk, to prevent its evaporation and too rapid 
drying; and it should, likewise, be covered by the 
gauze to prevent its adhesion. It is of great use 
in cases of sloughing ; mortification ; hospital gan- 
grene, &c. 

The Mustard Poultice, is prepared by mixing 
flowers of mustard with water, to the consistence of 
that which is commonly employed for the table, and 
then spreading it very thinly on muslin, allowing it 
to remain on the part only till it reddens it — be it 
five, or fifteen minutes. The vinegar with which it 
is sometimes mixed, so far from increasing its powers 
of stimulation, materially weakens them. 

Narcotic Poultices, or those containing opiates, as 
poppyheads, or powdered opium, &c., will sometimes 
prove very serviceable, and may be made by the addi- 
tionofany ofthesesubstancestotheEmollientPoultice. 

To confine a poultice to a part, some of the ban- 
dages hereafter mentioned may be employed, at the 
option of the surgeon. 

Plasters, are made of various substances, and are 
occasionally employed to soften indolent tumours, 
procure their resolution, or hasten their suppuration. 



APPLICATION OF DRESSINGS. 



41 



Fig. 26. 



Fig. 27. 



in their preparation, the surgeon has no part, as this 
properly belongs to the apothecary. He may, how- 
ever, be required to directthe shape of them, in order to 
ensure their more accurate application. In general, 
nothing is necessary but to slit the angles which pro- 
ject when the plaster is applied to the surface ; but 
in the plaster for the female mammae, a peculiar shape 
is required, which may be best obtained thus : — 
Fold a piece of paper on itself, so as to 
form a perfect square of the size required ; 
fold this so as to make an oblong square ; 
double it and fold its angles so as to 
make a smaller square ; fold this into a 
triangle, and round off its upper angles 
as in the dotted line (Fig. 26). Then 
cut off semicircularly, as much of the 
point as will make an opening large 
enough to admit the nipple, 
or more if desired ; and slit 
the sides, at the circumfer- 
ence, for one inch, towards 
the centre. This when open- 
ed out will give the figure 
required (as in Fig. 27), 
and will enable any one to 
spread a plaster of a proper 
shape. 

IRRIGATIONS, 

Or dressings by imbibition, is the term applied to cer- 
tain dressings which are intended to keep the parts con- 
stantly cool and moist, by the use of cold fluids, and thus 
diminish an excess of inflammatory action. In simple 
erysipelas of some extent; in phlegmonous erysipelas; 
in compound fractures ; in sprains ; dislocations, and 
other injuries to joints ; and in cases of sloughing 
from excessive action after amputations, they aflbrd 
us a most excellent means of combating the inflam- 




42 PREPARATION AND 

matory action. In order, however, that they may be 
properly applied, considerable care and attention is 
requisite on the part of the attendant ; for if the 
stream of the liquid is not kept up steadily, there will 
be a constant change in the temperature of the part, 
and a reaction from cold to hot, which will do harm 
by exciting an increased circulation in the part ; or 
there may be too great a degree of cold ; or the pa- 
tient become wet with the dressing and suffer from 
cold in some internal organ. As illustrative of the 
marked advantages of Irrigation, in the treatment of 
numerous injuries, we would here cite the following 
cases, reported by Mr. Gilchrist, of Aberdeen, in the 
British and Foreign Medical Review, for July, 1846. 

" 1st. A man received an injury by the machinery 
in a large paper-mill, which laid open the wrist-joint. 
The hand was half separated from the fore-arm ; the 
tendons were torn, and the inferior end of the radius 
which is naturally related to the carpus, was exposed ; 
the arm and hand were placed straight upon a pillow, 
the w^ound was cleaned, and two stitches taken ; a 
pledget of cloth soaked in cold water was applied, 
and a bandage rolled, not too tightly, round the hand, 
wrist, and forearm ; a large basin of cold water was 
placed conveniently by the bed-side, and directions 
left to apply freshly soaked cloths over the bandage, 
every two or three minutes, to prevent any heat or 
inflammation ensuing. No inflammation took place ; 
the modelling process was uninterrupted, without 
suppuration, and an excellent cicatrix formed in little 
more than a fortnight. 

"2d. A girl had the whole of the soft parts on the 
palm or surface of the four fingers, as it were scraped 
off, by the machinery in a flax-mill ; the tendons were 
torn, and the phalanges exposed at different places. 
Each finger was dressed as follows every day : being 
first bathed in cold water, a piece of soft cloth was 
placed round the finger, and a narrow roller to keep 



APPLICATION OF DRESSINGS. 43 

it applied ; when the fingers were all thus dressed, a 
larger cloth soaked in cold water was wrapped round 
them together, and changed as frequently as the 
slightest tendency to become heated reappeared. The 
modelling process advanced steadily without suppu- 
ration, and cicatrisation was completed in about four 
weeks. The fingers gradually acquired flexibility. 

'^ 3d. A little boy had scrofulous disease of the 
bones of the ankle-joint, on account of which I am- 
putated, by the flap operation, below the knee. Two 
stitches were used for two days ; a strip or two of 
plaster and cloths wrung out of cold water, were the 
sole applications. The wound was whole, in a week. 
Other amputations have been similarly treated, with 
equal success. 

" 4th. A girl received a sharp instrument into the 
ball of the eye, at the Woodside works. The cornea 
and sclerotic coat were ruptured ; the iris was lace- 
rated, and prolapsus followed. Rest in bed ; con- 
tinued persevering use of cloths wrung out of cold 
water, and simple laxative medicine constituted the 
treatment. The treatment was effectual in prevent- 
ing inflammation, which was clearly the only indica- 
tion in the case. The termination was as favourable 
as could be, under the circumstances." 

These cases are strong arguments in favour of this 
simple and ancient remedy, and might be supported 
by numerous others under our own observation, did it 
seem necessary. 

The simplest form in which irrigation can be pro- 
perly arranged, is that shown in the cut. (Figure 28, 
ABC). 

The part to which it is to be applied, is first laid 
upon a piece of oil cloth or coach-curtain, to prevent 
the wetting of the bed and clothes ol the patient. 
This should be bent on the outer side, so as to form a 
little gutter to carry off the water, after it has gone 
on the limb, into the vessel placed below. Then a 



44 



PREPARATION AND 



vessel filled either with cold water, cold lead-water, 
or other cold lotion, is placed near the bed at such a 
height as will be most convenient, and from it strips 
of patent lint twisted together ; or, what is better, a 
piece of cotton-wick, as A and B, made to extend to 
another piece of lint which covers the part affected, 
and absorbs the liquid brought over. The wick, 
previous to its application, should be so wet as to 
absorb readily the fluid in the basin, or, in other 
words, form a Syphon. 

Another mode of irrigation, which is rather neater, 
is by means of a tube with a cock, arranged as in the 

Fig. 28. 




rmri. 




cut at C, and which may be made at a moment's 
notice, by any tin-plater, or extemporaneously of 
a piece of cane-angle and some quills. 



APPLICATION OF DRESSINGS. 



45 



In either case, if the patient complains of the cold, 
it is easy, by means of the cock^ or by plugs of wood 
introduced into the quills, to regulate the amount of 
fluid which shall pass over. This is the only advan- 
tage which the latter apparatus possesses over the 
syphon, while the simplicity of the syphon, and the 
facility with which it may be made and applied, re- 
commend it strongly to our favour. 

Should it be desirable to foment the part, it is only 
necessary to change the liquids, though generally, the 
application of warmth can be more readily made by 
wringing flannels out of hot water, and changing them 
as they become cool. 



RULES FOR DRESSING. 

It will now be seen, that as the different articles 
employed in Dressings are very varied, and the cases 
to which they are applicable equally so, it is a diffi- 
cult matter to give special directions, as to their 
employment under one general head. Nevertheless 
there are certain rules founded on common usage, 
and such as experience has tested, that will be found 
advantageous to the young dresser, by anticipating 
difficulties that he would otherwise be unprepared 
for. Thus, the choice of the position of both surgeon 
and patient ; the selection of assistants ; the order in 
which the different articles are to be employed, &c., 
may readily be reduced to general laws ; whilst the 
modifications required for particular cases, can be 
treated of under a more special head. Before pro- 
ceeding then to any dressing, it is important that 
every step of it should be anticipated in order that 
nothing may be wanting. Proper assistants should 
also be ready, and each of them made fully to under- 
stand the duties that they will have to perform. 



46 PREPARATION AND 

Especially is this necessary in the treatment of cases 
in private practice, where the surgeon is often obliged 
to take his assistants from among the friends of the 
patient ; these, from their desire to aid the patient, 
are generally very ready and willing to perform what- 
ever may be asked of them, yet when actually en- 
gaged, become faint, sick, hurried, or otherwise un- 
fitted for duty, in consequence of some peculiarity of 
system, or from want of habit. Even medical men, 
will thus occasionally be thrown out of service, as 
very many are sickened by a bloody operation, or 
disgusted by a simple dressing, accompanied only by 
the smell of unhealthy pus, &c. Every surgeon must 
have frequently experienced this even in very simple 
cases, and will readily admit that the selection 
'of assistants often becomes a matter of the first im- 
portance. 

The observance of the following rules, in regard 
to dressing, will therefore be found to assist materially 
in all our operations. 

1st. Make, or see made, all that is requisite for 
the new dressing before removing the old one. 

2d. Have a sufficient number of capable aids, to 
whom special duties shall be assigned before com- 
mencing the dressing, as this prevents confusion ; 
thus, in dressing a stump, or wound, there should be 
one to support the limb ; another to furnish hot water, 
and change it as required ; heat the adhesive strips, 
hand cerate, &c., &c., by which means the surgeon 
can give his attention wholly to his own duty. 

3d. Arrange the bed, as a general rule, after the 
dressings are changed ; or, if in a case of fracture, 
before the patient is placed on it. 

4th. Let the position of the patient be such as will 
be as easy for him as possible, so as to cause him no 
unnecessary fatigue, and let the surgeon place him- 
self on. the outside of the limb, and with his face to 



APPLICATION OF DRESSINGS. 47 

the patient, as this will give him more freedom in 
his movements, and prevent any accidental jars. 

5th. Be especially careful to guard against all 
hasty and inconsiderate movements on the part of the 
assistants or of the surgeon, in order to prevent unne- 
cessary pain to the patient. 

6th. In all operations, let each assistant under- 
stand, before you begin, that he is to confine himself 
solely to his own duties ; thus, one may hand instru- 
ments to the operator; another sponge away blood ; a 
third see to ligatures, &c., &c., so that when a tena- 
culum or other instrument is wanted, there may not 
be half-a-dozen hands snatching for it, to the great 
risk of all parties. 



48 PREPARATION AND 



CHAPTER II. 



OF THE PREPARATION AND APPLICATION OF 
THE BANDAGE. 

By Bandaging, is generally understood the confine- 
ment, in their proper situation, of dressings and other 
surgical apparatus, or the retaining in their natural 
position of parts of the body which have been pre- 
viously displaced, by means of pieces of muslin or 
other substance, or by mechanical contrivances. The 
term Bandage, in its strict signification, is only appli- 
cable to a collection of bands, or to those pieces of 
stuff which are fastened to one another and employed 
as a whole ; though general usage now justifies its 
application to the single Band or Roller. This, is a 
strip of flannel, linen, muslin, calico, cloth, gum- 
elastic, or other substance ; and of different lengths 
and widths according to the object to be attained in 
its application. As most generally found, it consists 
of a strip, of muslin, eight or ten yards long ; one-half, 
two, two and a half, three, or four inches in width ; 
free from hems or darns ; soft, pliable, and unglazed, 
to prevent its slipping. As thus made, bandages are 
divided into two kinds : — Simple, or those formed 
by the application of the roller only ; and Compound, 
or those resulting from the complex arrangement of 
the pieces composing them, as in the double T, 
sling, &c. 

OF THE SIMPLE BANDAGE, OR THE ROLLER. 

The simple roller is prepared from a piece of mus- 
lin of the requisite length and width, by tearing it 



APPLICATION OF THE BANDAGE. 



49 




from the piece, and then winding it into a cylindrical 
form, either by the machine, or by the hand, so as to 
form one or two heads, and constitute what is called 
the Single or Double-headed Roller. The machine 
for rolling them, one of Dr. Barton's earliest contri- 
butions to Surgery, is 
seen in Figure 29, and Fig. 29. 

consists of a base A, 
and of two uprights, B 
B, in which runs a spin- 
dle, G, to receive the 
bandage ; a broader 
upright, C, to support 
a moveable frame, F, 
which, by its pressure, 
tends to tighten the 
bandage, D D, as it is rolled, and of a screw, E, to 
fasten the machine to a table. Various other ma- 
chines are used by different surgeons, so modified as 
to suit peculiar views ; but the principle of all, is 
that here shown. 

In rolling the bandage onanyof these, one extremity 
should be attached to the spindleby wrapping it around 
it, and the rest, wound up by turning the handle with 
onehand,whilethe other, directsthe course of the band 
and ensures its being wound evenly. Then tear off 
all the loose threads from the end of the cylinder, 
before it is used, as they will not unravel too much 
if the cylinder is tightly rolled, but will be much in 
the way of its application ; but if the threads are torn 
from the strip before it is formed into the cylinder, a 
large portion of it will be wasted in ravellings. 

Thus formed, the Single-headed Roller consists of 
a cylinder with two extremities; 
of an initial or free end ; of a 
terminal one, or that found in 
the centre of the cylinder ; of 
two surfaces, an external and 



Fig. 30. 





50 PREPARATION AND 

an internal, and of a body, or portion between the 
two ends. 

The Double-headed Roller, has the same parts 
as the single one, except the 
initial end, which is wanting, 
both ends being here wrapped 
into cylinders. This roller, there- 
fore, always commences in its 
application with the body, or 
portion between the two heads. 
The necessity which exists for the re-application of 
the same roller, both from economy and convenience, 
sometimes compels us to prepare it without the aid of 
the machine, because, unless a roller is formed into 
a cylinder, it will be found impossible to apply it pro- 
perly. In order, therefore, to do this with the greatest 
ease, fold the terminal end of the roller five or six 
times on itself, so as to form a sort of axis or mass ; 
and roll this a few times on the thigh, to give it size. 
Then place its two extremities between the thumb 
and forefinger of the left hand, while the body is 
allowed to run over the forefinger of the right, and 
press it firmly by the thumb of the hand used, so as 
to make a considerable degree of traction, and tighten 
the cylinder. Having arranged this, give a rotatory 
motion to the band, by causing the cylinder to revolve 
upon its axis by means of the fingers and thumb of 
the left hand, whilst, at the same time, the right re- 
volves partially around the cylinder itself, which, by 
this compound movement, is soon formed as required. 
In the cut, the action is shown reversed. 

After a very little practice, it will be found an 
easy matter thus to roll a bandage with either hand, 
almost as quickly and tightly as can be done on the 
machine, although at first, it will seem to be very 
awkward. 

When the roller is intended for the body, it should 



APPLICATION OF THE BANDAGE 51 

be twelve yards long and about four inches wide ; 
when for the head, five yards long by two inches 
wide ; when for the extremities, eight yards in length, 

Fi^- 32. 




and two, two and a-half, or three inches in width, 
according to the size of the limb, the thigh requiring 
one a little wider than that for the leg. 

In order to apply the single-headed roller, which 
is the one most generally employed, it should be 
held between the thumb and fingers of the right 
hand, and the cylinder pressed by the fingers against 
the palm, to prevent its slipping out of the hand as 
it unrols, which it is apt to do, if held so that its 
internal surface should be the part first applied to the 
body. Or, it may beheld by placing the thumb and 
first and second fingers of the right hand on the two 
extremities of the cylinder. In either case, the external 
surface of the initial end, should be the portion first 
applied to the part, and should be retained there by 
the fingers of the left hand until one or two turns are 
made round it, so as to fix it firmly ; after which we 
may proceed up the limb. 



52 PREPARATION AND 

Bandages have been divided into several kinds ; 
1st. from the direction which they take in covering 
the part ; and 2d. the object to be attained by 
their application ; thus, we have the Circular ; the 
Oblique ; the Spiral ; the Figure of 8 ; the Spica ; 
the Recurrent ; and we have also the Uniting, 
Dividing, Compressing, Expulsive, Retaining, &c., 
whether made by the Simple or Compound Ban- 
dages. 

The Circular, is that formed by horizontal turns 
of the roller, each of which overlaps, or very nearly 
overlaps, the one which preceded it. 

In the Oblique, the turns gradually ascend the 
limb, or pass obliquely to its axis. 

The Spiral, mounts still more ; — the Spica, forms 
a figure like the leaves of corn ; and in the Recur- 
rent, the folds run back to the point whence they 
started. 

The Uniting Bandage, named from its action, is 
that which is used to bring together the edges of 
wounds ; it should be adapted to their direction 
according as they take a longitudinal or transverse 
course, and will be again referred to under the Treat- 
ment of Wounds. 

The Dividing Bandage, is that which is used to 
prevent the formation of cicatrices in the treatment 
of burns, and of wounds, attended with great loss of 
substance. 

The Compressing Bandage, is used for exerting 
compression in cedematous swellings, callous ulcers, 
varices, aneurisms, &c. 

The Expelling Bandage, is employed in the treat- 
ment of deep-seated abscesses, fistulae, contused 
wounds, &c. It consists of a roller applied over 
compresses, upon the region wherein the matter to be 
expelled is placed, and acts by preventing these fluids 
from travelling along the interstices of the muscles, 



APPLICATION OF THE BANDAGE. 53 

and detacliing the skin from the subjacent parts, thus 
forming sinuses. 

Retaining Bandages, are those which serve to con- 
fine dressings and displaced parts in their proper situa- 
tion, as those for fractures and dislocations. 

A bandage which does not give the most perfect 
support to the parts, maintain them in the position 
necessary to ensure the fulfilment of the indication 
proposed, and exert on the member an equable com- 
pression, is useless, or worse than useless, as it may 
produce such a state of things as will eventuate in 
the loss of the limb, or even of life. When, therefore, 
it is applied too tightly, or when the compression is not 
uniform, very serious consequences may arise, such 
as oedematous swellings, or even mortification : 
their proper application is, therefore, a matter ot 
great importance. 

In no department of surgery, will the reputation of 
the young practitioner be more seriously involved, 
than in that referring to the application of the ban- 
dage, and we accordingly find that in nearly every 
period, its importance has been strongly insisted on. 
Dr. Hennen, one of the most practical and distin- 
guished men of his time, says " too much attention 
can scarcely be paid to this portion of the surgeon's 
duty ; our young surgeons may study, philosophise, 
and reason well, but neither books nor reflection, nor 
arguments, will teach the application of a bandage 
without repeated practice." Practice alone can give 
that manual dexterity so necessary for its proper em- 
ployment ; and unless a bandage is properly applied, 
it had better be omitted ; for if too loose, it will not 
fulfil its indication ; and if too tight, may produce gan- 
grene. The practitioner's reputation is also liable to 
considerabie injury, not only from the result of the 
case, but also from the judgment of those around 
him, if he should be ignorant of this important duty. 



54 PREPARATION AND 

The majority of persons are ever attentive to the 
manipulations of any workman, and can soon judge, 
and judge correctly, whether or not he is acquainted 
with his business ; consequently they do not hesitate 
to exercise their criticism to its fullest extent, in 
the case of the surgeon ; and when their opinion of 
his ignorance, is confirmed by the patient's suffering, 
they are ever ready to disseminate it widely. On 
the contrary, when a bandage lays smooth and regu- 
larly on the limb, when the patient is relieved from 
previous torture, and the case assumes the neat ap- 
pearance, that always follows the visit of an expe- 
rienced dresser, the confidence of all parties is raised, 
and the subsequent visit is looked forward to, with 
confident anticipations of relief. 

Those who, from want of practice, cannot produce 
the neat appearance of a well applied bandage, and 
thus escape the remarks so often made in regard to 
it by those around the patient, are frequently in- 
duced, in order to effect it, to resort to the wetting of 
the roller, as it then adapts itself much more readily 
to the part. But this should never be done except 
in the treatment of Dislocations, unless we would 
wish to expose a patient to the risks of mortifica- 
tion ; for it is impossible for any one to calculate 
exactly, how much a wet roller will shrink in drying, 
and consequently how great a degree of pressure it 
will make on a part, after w^e have left it. A 
handage may be of the proper degree of tightness, 
and the patient make no complaints, and yet in three 
or four hours, be suffering such agonies, as must be 
seen or felt, to be properly appreciated. The ques- 
tion, then, may very properly be asked, as to how 
much traction should be made, in order to apply a 
roller properly. This will, to a certain extent, de- 
pend on the object with which it is applied, as a 
bandage which is merely intended to confine a dress- 



APPLICATION OF THE BANDAGE. 55 

ing, need not be as tight as one that is used to compress 
the muscles ; but, as a general rule, a dry bandage is 
not too tight, if the patient feels easy under it, two or 
three hours after its application ; until then practice 
has taught the degree to which a roller should be 
drawn, the fact should be recollected that one which 
is too tight must do serious injury, while all that can 
result from one that is too loose, will be the non-ful- 
filment of the indications for its application. The 
young surgeon had, therefore, better err in the latter 
case, as daily evidence shows that the tendency of 
all young dressers is to use too much traction on a 
bandage, and not too little. But it should be born 
in mind, that as the proper application can be readily 
gained, any defect arising from it should very justly 
be charged on the surgeon. 

In the consideration of the special application of 
the roller, w^e shall take up : 1st, its application, ac- 
cording to the course which it may take ; and 2d, 
that resulting from the object to be attained in its ap- 
plication, commencing with the head, and proceeding 
regularly to the toes. 

The Circular Bandage, is one, as has been said, 
in which each turn over- 
laps that which has pre- 
ceded it, so that the 
whole looks like a sin- 
gle turn, and runs di- 
rectly round the part. 
All the circular bandages 
are very simple, and con- 
sist of, one for the Fore- 
head, in which the turns 
encompass the vault of the cranium ; one for the Eyes, 
as to retain dressings after the operation for cata- 
ract ; one for the Neck, as in the dressing of blisters, 
setons, &c. ; one for the Arm, as in the compression 




56 



PREPARATION AND 



Fig. 34. 




of the veins previous to bleeding ; and a few of a like 
nature for other parts of the body, as may be readily 
understood. 

In the confinement of the terminal end of the cir- 
cular, or any other bandage, two means are em- 
ployed, — 1st. the use of pins; 2d. of little bands tied 
in bow-knots. 

If pins are used, they should be placed either in 
the direction of the length, or breadth 
of the band. If in its length, the 
head should always be turned from 
the free end of the roller, (Fig. 34) 
otherwise the tendency of the roller to 
become loose, by constant drawing 
against the head, will, at last withdraw 
the pin entirely. On the other hand, 
if it is applied transversely, the head 
should always present to the upper 
extremity of the limb, in order to pre- 
vents its sticking in the fingers of the surgeon when 

his hand is passed 
Fig. 35. Fig. 36. down the part either 

to smooth the turns of 
the roller, or to seek 
for the end in its re- 
moval. (Fig. 36.) A 
reference to Fig. 35 
will show how the pin 
may be drawn out by 
the unwinding of the roller itself. Some persons 
prefer fastening the end of a roller by means of a 
piece of tape, or by slitting it for a short distance into 
two strips and tying the pieces in a bow-knot; (Fig. 37) 
but this is never as neat or firm as the pin, except in 
bandaging fingers, toes, &c., where it is rather more 
convenient. 

The Oblique Bandage, diflfers from the circular, in 
its turns being less at right angles to the axis of 




APPLICATION OF THE BANDAGE. 



57 



the limb, in consequence of which it is enabled to 
cover in a greater ex- 
tent of surface, each Fig. 37. 
turn passing a little 
beyond the one pre- 
viously made, and fol- Ml'' J'' MW\ >^^ 
lowing a course which 
leaves a considerable 
space between them. 
It is chiefly employed 
to retain dressings, 
although occasionally 
useful, especially when conjoined with other bandages 
in cases, which will be treated of hereafter. 




Fig. 38. 




The Spiral, is the bandage most frequently em- 
ployed in the treatment of affections of the extremi- 
ties, as well as in those cf the trunk. Its turns ascend 
less rapidly, are closer together^ and cover in the part 
much more firmly than the last, thus making a certain 
amount of pressure, in addition to the retention of a 
dressing. Each turn covers in at least one-third of the 
one below it, and as most of the parts to which it is 
applied are conical in their shape, especially the extre- 
mities, it follows that, in the ascent from the lower to 
the upper part of them, we must pass from the apex of 
the cone to its base, and that consequently one edge 
of the roller will press on the part, while the other 
will project beyond it, thus forming what are designated 



58 



PREPARATION AND 



as Gaps, as a, 6, c(Fig. 39). To obviate this, and cause 
the bandage to apply itself more perpendicularly to 

Fis'. 39. 




the whole surface of the part, in other words equalise 
the pressure, the roller must be half folded on itself, 
or a doubling made, which is called a Reverse. As 
the bandage by this action acquires an increased 
thickness, a greater degree of pressure will be made 
on these points than at any other, and it is therefore 
desirable, in order to obviate the welts, and other 
bad effects occasionally resulting from them, that the 
reverse should be as short and as smooth as possible. 
To make it, is therefore a matter of much import- 
ance, and constitutes the first difficult step in ban- 
daging, because its mechanism is not sufficiently 
attended to. The following rules, which long usage 
has confirmed, will render the matter perfectly simple, 
and if observed, make it very difficult to prevent 
its proper formation : — Hold the roller, as before di- 
rected, in the position in which it is generally 
applied, that is, either by its body or its two extre- 
mities, the hand being in a state of supination ; apply 
the initial extremity to the limb, and continue the 
simple spiral turns, until we approach the enlarged 
portion of the limb ; then, apply the fingers of the 
other hand, firmly to that portion of the bandage 
which is already in contact with the limb, not to 



/ 



APPLICATION OF THE BANDAGE. 59 

assist in forming the reverse, or to fold it down, but 
simply to prevent its slipping or becoming relaxed 
while the reverse is being made. This being fixed, 
see that no more of the band is unrolled than will 
enable us to separate the hand a short distance, say 
four or six inches from the limb ; then keeping all 
slack between the fingers which fix the body of the 
roller, and the part which is in the cylinder, turn the 
hand holding the cylinder from supination into de- 

Fig. 40. 




cided pronation, by a simple motion of Ihe wrist 
alone, without moving the fingers from the cylinder, 
(Fig. 40) — taking care to make no traction, nor 
to sink the cylinder below the level of the limb till 
the fold or reverse is made, when we may again 
proceed up the limb, recollecting that each turn 
ascends spirally, and only covers in about one-third 
of that which preceded it, so as to keep each edge 
and each reverse parallel to its fellow. 

These reverses being indispensable wherever there 
is an increase in the size of the part, as from the extra 
development of certain muscles, it is of the greatest 
importance that the proper way of making them 
should be acquired, as no spiral bandage can well 



60 



SPIRAL BANDAGES. 



proceed six inches on an extremity without requiring 
a reverse. Although generally regarded as the most 
difficult point in the application of the roller, it is 
not so in reality, and a little attention to the rules, 
especially while the reverse is being formed, that no 
traction be made, nor the cylinder sunk below the 
limb, or widely separated from it, will enable any 
one after a little practice to make them with great 
ease and neatness. To add to the latter, they should, 
as far as possible, be kept in a perpendicular line, as 
seen in the cut of the spiral of the lower extremity. 
This will always result from keeping the edges of 
each turn parallel. We repeat that the difficulties 
experienced in making reverses, and the terrible, 
twisted, and corded things, sometimes made for re- 
verses, are always the result of traction in the ban- 
dage, while the reverse is making. 

The special applications of the Spiral Bandage are 
as follows : — first. 



THE SPIRAL OF THE CHEST. 

This requires a single-headed roller, ten or twelve yards 

long, and three or 
J^i^.^i' four inches wide, and 

that the patient should 
be sitting up, in or- 
der that the hand of 
the surgeon may pass 
readily behind his 
back. In applying it, 
place the initial ex- 
tremity on the ante- 
rior part of one axilla, 
say the left ; and con- 
duct the roller up- 
wards across the front 
of the chest ; pass 

over the right clavicle, and over the back to the point 




SPIRAL BANDAGES. 61 

of departure, another and similar turn being effected 
so as to make one or two oblique turns of the neck 
and that axilla, whence it started. Then carry it 
across the front of the chest to the right axilla, to 
form an oblique of this axilla, and the left clavicle ; 
after which, carry it firmly around the chest in spiral 
turns from above downwards, drawing each turn with 
firmness, so as to compress the ribs, and oblige the 
patient to breathe by the diaphragm and abdominal 
muscles. 

Use. — In fractures of the ribs or of the sternum, 
care being taken to apply compresses to their ante- 
rior and posterior extremities, if the fragments pro- 
ject inwards ; but if outwards, only upon the parts 
themselves. It is sometimes useful to add to this the 
T bandage for the body, as seen hereafter, in order 
to prevent the roller from slipping, if the patient, 
from mania a potu or other causes, should be very 
restless; but generally, the oblique turns of the neck 
and axilla serve this purpose. 

THE SPIRAL OF THE ABDOMEN, 

Is composed of the same bandage as the above. But 
in its application, commence at the lower part of the 
chest, and carry the roller spirally round the abdo- 
men from above downwards, adding to it a single T, 
or make one or two oblique turns around the thighs, 
to prevent its slipping upwards. 

Use. — To compress the abdomen, as in certain 
cases of tympanitis, or after the operation for tapping 
in ascites ; but its place may be well supplied by a 
double T of the abdomen, where firm pressure is not 
required. 

THE SPIRAL OF THE PENIS, 

Requires a bandage of eighteen or twenty -four inches 
in length, half an inch wide, and slit into two pieces 



62 



SPIRAL BANDAGES. 



Then coramence at the 



Fig. 42. 




at its terminal extremity, 
glans penis, and form an 
ordinary spiral which shall 
terminate at the root of the 
penis, and be confined 
there by tying the two 
ends (Fig. 42.) 

Use. — This is chiefly 
employed to retain dress- 
ings to the penis, in cases 
of chancres and other sores 
external to the prepuce. 
It has also been used in 
the treatment of gonor- 
rhoea, in order to compress 

the urethra, a catheter being left in it ; but it is very 
apt to produce erections, which do harm, and quickly 
derange the bandage. The sheath of the penis spoken 
of hereafter, answers better in many instances, and 
especially in gonorrhoea. 

THE SPIRAL OF THE UPPER EXTREMITY, 

Requires a roller, eight yards long, two or two and a 
half inches wide, and compresses, if it is to be used 
to make pressure on particular parts, and act as a Com- 
pressing Bandage. In its application, having covered 
in the fingers, if necessary, by the gauntlet, as shown 
hereafter, commence with one or two circular turns 
around the wrist, in order to fix the end of the ban- 
dage ; then pass obliquely over the back and palm of 
the hand, to reach the extremities of the fingers, and 
ascend by three spiral turns w^ithout reversing, until 
we reach the phalangeo-metacarpal joint of the 
thumb ; cover this and the wTist-joint by a figure of 
8, such as is described hereafter, and ascend the limb 
by simple spiral and reversed turns, till we reach the 
elbow. Cover this also by a figure of 8, if the arm 
is to be flexed ; if not, by simple spiral turns without 



SPIRAL BANDAGES. 63 

reverses, and continue the spiral and reverse turns to 
the shoulder, placing compresses, &c., where they 
may be required (Fig. 43.) 

Fig. 43, 




This bandage is daily used to cover in, sup- 
port, and compress the arm, as in varicose veins, 
aneurismal tumours, treatment of fractures, &c., and 
is with the exception of the turns for the elbow, per- 
fectly easy, and attention to the figure of 8 bandages 
will soon overcome this difficulty. 

Its effects, when well applied, are excellent ; but it 
may become very fatiguing and painful if drawn tight, 
and if too tight, may produce gangrenous ulcer, &c. 
In 1837, it was found necessary in the Pennsylvania 
Hospital to amputate the forearm of a man who had 
only a simple fracture of the lower extremity of the 
radius, but whose arm was gangrenous from the mal- 
application of this bandage, by a country surgeon. I 
would recommend those who are desirous of avoiding 
such consequences in this or other bandages, to have 
them applied to their own persons, and they will soon 
learn the proper degree of tightness, especially if 
allowance be made for subsequent swelling. 



64 



SPIRAL BANDAGES. 



THE SPIRAL OF THE FINGER, 

Is composed of a roller, known as a finger bandage, 
which is only one inch wide, and of the requisite 
length, say one yard, split into two ribbons, at its ter- 
minal extremity. 

The spiral turns of this little bandage are em- 
ployed by every one to retain dressings to the finger 
in cases of wounds, but without a turn round the 
wrist, as it is very apt to become deranged. 

Fix, therefore, the initial extremity round the wrist 
by a circular turn, and cross the back of the hand, in 
order to descend either finger to its extremity by very 
oblique turns. Then commencing at its extremity, 
make an ordinary spiral with reverses, and terminate 
the bandage either by a knot on the fingers, as seen in 
Fig. 37, or with a few circular turns round the wrist. 

THE SPIRAL OF ALL THE FINGERS, OR GAUNTLET, 

Requires a band, eight yards long and of the preced- 
ing width, rolled into a 



cylinder. Then com- 
mence, as before, by one 
or two circulars around 
the wrist ; pass obliquely 
over the back of the hand, 
and descend by oblique 
turns to the nail of the 
forefinger, after which as- 
cend by spiral and re- 
versed turns, to its base ; 
pass to the middle finger; 
descend by oblique turns 
to its nail ; ascend by spi- 
rals to its base, and so on, 
till all the fingers are cov- 
ered in, terminating at the 
base of the little finger. 
Then pass in front or on 
the back of the hand, to 
finish by circulars around the wrist. 



Fig. 44. 




turn 



SPIRAL BANDAGES. 



65 



in the cut is represented as much too wide; those on 
the fingers and hand are more correct. 

Use. — We may resort to this bandage when more 
than one finger is injured, and there is reason to fear 
their uniting if they are permitted to come in contact, 
as in cases of burns. To this, should be added the 
demi-gauntlet, double T of the hands, or perforated 
T, as hereafter shown, if there is a necessity for re- 
taining dressings at the metacarpal extremities of the 
fingers, or the inter-digital spaces. 



THE DEMI-GAUNTLET, 

Is formed of the same 
pieces as the preceding, 
and applied by making a 
few circular turns around 
thewrist, and then passing 
across the back or palm 
of the hand, as the case 
may be, by oblique turns 
which will pass from the 
root of each finger, or its 
interdigital space, to make 
a circular turn round the 
wrist (Fig. 45.) 

This very light ban- 
dage is chiefly useful in 
retaining dressings to the 
front or back of the hand. 
Its place may, however, be 
supplied by the perforated 
T, or the double T of the 
hands. 



Fi^-. 45. 




As the Spiral of the Thigh, of the Leg, of the Foot, 
and of the Toes, are all similarly applied, they may 
be readily included in 



6 SPIRAL BANDAGES. 

THE SPIRAL OF THE LOWER EXTREMITY. 

This requires two single-headed rollers, each eightyards 
longandtwo and a-haif inches wide, and thatthe patient 
be seated with the extremity of his heel on the very 
point of the surgeon's knee, or else lieing down, 
with the leg supported by assistants. The surgeon 
being either at the foot, or on the outside of the 
limb, and either sitting or standing, commences by 
making one or two circular turns, from without in- 
wards, immediately above the malleoli, in order to 
fix the end of the roller ; he then descends, if in the 
right foot, from the external malleolus obliquely across 
the instep and under the sole to the extremity of the 
little toe ; from this he makes two or three oblique turns 
upwards, so as to cover in the foot as far as the instep, 
and then covers in the heel by turns of the figure of 
8, one extremity of the eight embracing the heel and 
ankle, the other the instep. After this he ascends 
the limb by spiral reversed turns, made with either 
hand, until he reaches the knee ; this joint being 
covered in by a figure of 8, he then proceeds with 
the second roller, to make spiral reversed turns on the 
thigh, till the whole limb is covered. 

Use. — This bandage, if well applied, fulfils every 
indication required of a bandage in fractures, ulcers, 
varicose veins, or oedema, and will usually keep 
its place for two or three days without being re- 
newed, if the patient remains in bed. The main 
difficulty to its application, consists in the co- 
vering in of the heel. This is not absolutely ne- 
cessary, as in many cases the close adhesion of the 
integuments to the parts below, prevents any great 
amount of swelling ; but where a considerable de- 
gree of compression is to be made on the leg, as in 
the treatment of varices, fistulse, &c., it is a better plan 
to cover it. To do this, proceed from the inside of the 
instep, say of the right foot, over the point of the heel ; 
come up over the outside of the instep ; down on its 



SPIRAL BANDAGES. 



67 



Fig. 46. 




Fig. 47. 



inside ; under the sole of the heel, folding in the loose 
edge of the previous 
turn ; then around back 
of the heel to the inter- 
nal malleolus ; over the 
front of the ankle ; under 
the sole of the instep ; 
round the back ofthe heel; 
over the external malle- 
olus ; in front of the an- 
kle ; under the instep to 
the outside of the foot, 
and then up over the front of the ankle to the internal 
malleolus ; round the back of the 
leg to its outside, and then up the 
limb. The turns on the heel and 
foot when completed, are seen in 
Figure 46. The advantages of 
the circular turns round the 
ankle in commencing this ban- 
dage, are, that it gives greater firm- 
ness by preventing the initial end 
from becoming loose. The French 
surgeons, however, usually begin 
it at the toes, and do not cover 
in the heel, and their course may 
be pursued by those who may pre- 
fer it, by observing the rules for 
the application of 

THE FRENCH SPIRAL. 

This is formed by a roller, two 
and a-half inches wide, and seven 
yards long, which is used as fol- 
lows. Place the initial extremity 
of the roller on the outside of the 
instep, say of the right foot, and 
pass obliquely across to the ball of 
the big toe ; under the sole to the extremity of the 




68 SPIRAL BANDAGES. 

little toe ; and then make as many spiral reversed 
turns as will carry us to the front of the ankle, or the 
front of the astragalus. Pass from this around the 
malleoli, and ascend the limb by spiral reverses, as 
in the former bandage. The reverses of this and the 
former bandage being the same, are shown in Fig. 
47, the main difference in the two being in the turns 
covering the heel, and in the point of commence- 
ment. 

This bandage is used for the same purposes as 
the ordinary spiral just described, but especially for 
the application of the Dextrine or Starch Bandage, as 
it leaves the toes and heel open to inspection, which 
is all important, and will be again referred to in the 
treatment of fractures. Where it is necessary to make 
pressure on the instep, heel, or ankle, the Spica of 
the foot should be added to this, (see Fig. 62). 



THE CROSSED, OR FIGURE 8 BANDAGES. 



69 



CHAPTER III. 

OF THE CROSSED, OR FIGURE OF 8 BANDAGES. 

These compose some ofthe best and neatest applica- 
tions of the roller, and are so named from their shape. 
They are exceedingly useful in covering in joints and 
other points requiring a firm and solid compression, 
and may be made either with the single or double- 
headed roller, though, as the compression resulting 
from the turns of the latter is sometimes very painful 
and requires watching, it is seldom employed in this 
portion of the United States. 

THE CROSSED OF ONE EYE, 

Is made of a single-headed roller, two inches wide 
and five yards long. 

If the hair is long, cover in the head with a night- 
cap previous to the application of the bandage, as 
this will prevent the turns of the roller from slipping ; 
then make two or three circular turns, round the fore- 
head and occiput, passing from right to left if for the 
left eye, and the reverse, if for 
the right. On reaching the nape Fl^.is. 

of the neck in the third turn, 
carry the roller under the ear of 
the affected side, and then ob- 
liquely up over the jaw and the 
injured eye, inclining it well to 
the internal canthus, so as to 
cover the root of the nose, but 
not so as to affect the sound eye. 
Pass hence, across to the temple 
of the sound side ; descend to the 
nape ofthe neck, and make thus 
two or three oblique turns, termi- 
nating by circular ones around the forehead. 




70 THE CROSSED, OR 

Use. — This answers tolerably well to retain dress- 
ings to the eye, but is very readily displaced by the 
movements of the patient, unless pinned fast to the 
cap first applied. When it is desirable to make 
pressure on the ball of the eye, as in the treatment of 
gonorrhceal ophthalmia, cancer, &c., &c., we will 
find this bandage useful ; but we prefer the simple 
circular bandage of the eyes, for simple dressings. 

THE CROSSED OF BOTH EYES, 

Is made by a single or double-headed roller, seven 
yards long and two inches wide, with compresses, 
if required. 

In its application, make two or three circular turns 
of the head, turning indifferently from right to left, 
or the reverse ; then on reaching the back of the neck, 
pass under the ear of either side, up over the eye, 
root of nose, and parietal protuberance of the oppo- 
site side, to return to the neck. Make two or three 
turns similar to these, and at the third turn, pass from 
the parietal protuberance, round the forehead, instead 
of round the occiput, cross the root of the nose, the 
eye, and cheek of the opposite side, making an X 
with the first turns, and proceed in oblique turns as 
before ; terminating by circular ones. 

Uses. — This bandage, on account of the crossing 
of the turns on the forehead, is much more solid than 
the former, and may be employed in similar cases. 
It will add, however, even to its solidity to cover 
in the head, after its application, with a handkerchief 
or nightcap. 

THE CROSSED OF THE ANGLE OF THE JAW, 

Requires a single-headed roller, two inches wide, 
five yards long, and a thick compress. 

In applying it, carry the initial portion of the ban- 
dage around the forehead, and fix it by two circular 



FIGURE OF 8 BANDAGES. 



71 



turns of the vault of the cranium, turning from the 
right to the left and backwards, if the disease is on the 
left side, or vice versa. From the nape of the neck, 
direct the roller close under and behind the ear of the 
sound side ; under the jaw 
to the angle of the jaw on Fig. 49. 

the injured side, and place 
the compress behind and 
on this angle. Then carry 
the roller over the com- 
press, up over the side of 
the face, between the eye 
and left ear, obliquely 
over the vertex, and down 
behind the ear opposite 
the injured side. Make 
thus three or four oblique 
turns, as seen on the right 
side of the cut, and ter- 
minate by circular turns 
around the forehead. 

Use. — This is an excellent bandage for the treat- 
ment of fracture of the neck and angle of the jaw, and 
the only one that we know of, that fulfils the indica- 
tions for the treatment of this injury; as it forces the 
angle forward to the anterior portion, and counteracts 
the action of the pterygoid muscles. It will also be 
found useful in tumours of the parotid region ; and 
generally, in retaining dressings to this part. No 
circular turns should be made around the chin and 
neck, as sometimes recommended in the treatment of 
fracture of this part of the jaw, as these tend to dis- 
place the fragments, and push the chin too much 
backwards. 




BARTON'S BANDAGE, 
OR THE CROSSED, OR FIGURE OF 8 OF THE JAW, 

Is formed by a single-headed roller, five yards long 



72 



THE CROSSED, OR 



Fig. 50. 




and two inches wide, the initial extremity of which 

should be placed justbelow 
the prominence on the os 
occipitis. Then continue 
the roller obliquely over 
the centre of the parietal 
bone ; across the junction 
of the coronal and sagittal 
sutures ; over the zygomatic 
arch; under the chin, and, 
pursue the same direction 
on the opposite side, until 
youarrive at the back of the 
head ; pass then obliquely 
around and parallel to the 
base of the lower jaw; over 
the chin, and continue the same course on the other 
side, till it ends where you commenced ; whence it 
runs exactly the same course as before^, and ends by 
placing a pin at the vertex. 

Use. — For this beautiful specimen of a bandage, 
we are indebted to the skill and ingenuity of Dr. J. 
Rhea Barton, of Philadelphia, a surgeon to whom the 
profession owe many very important and novel oper- 
ations, and whose skill in the use of bandages is un- 
surpassed by any one; and although it may be 
looked on as a small affair compared with some of 
his improvements, yet it is perhaps the one most likely 
to be tried by the generality of practitioners, being, 
we think, the very best dressing for fractures of this 
bone, anterior to its angle, and one, that will 
please both patient and surgeon. In order to apply it 
neatly, the roller should not be over two inches wide, 
and the turns should be made to follow as nearly as 
possible, tjiose which have preceded them, thus giving 
the appearance of but a single turn. 

THE CROSSED, OR POSTERIOR 8 OF THE CHEST, 

Requires a roller, five yards long, tw^o and a-half or 



FIGURE OF 8 BANDAGES. 



73 



three inches wide, and compresses, tow, or cotton, 
to place on the anterior edge of the axillse to prevent 
the bandage from chafing them. Then, whilst the 
patient is sitting with the shoulders well drawn back 
by an assistant, and the compresses are held in front 
of the axillae till after the first turns of the roller, carry 
the initial extremity of the roller around the superior 
part of one arm, say the left, and make three or four 
spiral reversed turns from before backwards, and from 

Fig. 51. 




within outwards. From this shoulder pass obliquely 
over the back to the right axilla, the shoulders being 
now forced backwards. Ascend in front of, and over 
the shoulder, pass over the back to the left axilla, 
over the compresses in front of this and round to the 
back ; over it to the right axilla ; over it in front ; and 
over the back to the left axilla. Pass again the same 
coursetill the roller is nearly exhausted, when it maybe 
terminated by circulars of the body, or of the right arm. 



74 



THE CROSSED, OR 



Use. — This bandage will act either as a uniting 
one for the back, or a divisive one for the front of 
the chest, and was formerly much employed in the 
treatment of fractured clavicle ; but as its place has 
since been supplied by others, which are better, it has 
consequently fallen into disrepute, though it may oc- 
casionally be a useful addition to the means of treating 
such accidents, especially where it is requisite to carry 
the shoulder well backwards. It will also prove 
useful in uniting longitudinal wounds of the back, or 
in preventing contractions from burns, &c., on the 
front of the chest. 



THE ANTERIOR 8, OR CROSSED OF THE FRONT 
OF THE CHEST, 

Is precisely the reverse in its action of the one just 

Fig-. 52. 




described, although its composition is the same. Its 



FIGURE OF 8 BANDAGES. 



75 



application can therefore be readily understood from 
the figure, and what has been just said. It draws the 
shoulders forwards — would, of course, unite longi- 
tudinal wounds over the pectoral muscles, and pre- 
vent contractions in the cicatrices of burns on the 
back. By placing compresses over the upper part of 
the sternum, it may also be usefully employed in in- 
juries of this part, as well as in dislocations anteriorly, 
of the sternal ends of the clavicles. 



THE SPICA OF THE SHOULDER, 

Like most of the spica bandages forms one of great 
neatness, and well calculated for making pressure on 
this part. It is formed by a roller, eight yards long, and 
two and a-half inches 

wide, with cotton, Fig. 53. 

or compresses, for 
the axilla of the in- 
jured side. 

In applying it, we 
commence the ban- 
dage by making one 
or two spiral revers- 
ed turns round the 
upper part of the arm 
of the injured side, 
passing from with- 
out inwards, and 
from before back- 
wards : then pass 
from behind the arm, 
up over the lower ex- 
tremity of the same 
shoulder ; obliquely 
downwards, over 
the front of the chest 
to the axilla of the 
sound side; thence round the back; obliquely upwards, 




76 THE CROSSED, OR 

over the shoulder, and down in front, under the 
axilla of the injured side, which should be previously 
furnished with the compress or cotton, in order to 
protect it. From this point, we go behind and over 
the shoulder, to pursue exactly the same course, as 
before, each turn covering in, however, only one- 
third of the preceding turn, until the bandage is 
nearly exhausted ; when it should be made to termi- 
nate by one or two circulars of the trunk, or of the 
arm, or be pinned, as in the cut. 

Uses. — This beautiful bandage, named from the 
resemblance in its folds to the arrangement of the 
leaves of an ear of corn, exercises a very exact com- 
pression around the extremity of the shoulder, at a 
point where it would otherwise be difficult to make 
it. In cases of dislocation of the humeral extremity 
of the clavicle, it will be found of great service in 
keeping the clavicle reduced, especially if the arm be 
also well supported. But care is especially requisite 
to protect the edges of the axilla, as otherwise they 
will certainly be injured by the turns of the roller. 

When this bandage is made to mount gradually 
from the point of the shoulder towards the neck, it is 
called a Spica JiscendenSj but if its turns come from 
the neck to the shoulder, it becomes a Spica Descen- 
dens. Of course, it is optional with the surgeon to 
make either the one" or the other, as the result depends 
on the point where the first turn is placed after leaving 
the arm, in order to cross the chest. 



THE FIGURE OF 8 OF THE NECK AND AXILLA, 

Is formed by a roller, five yards long and two inches 
wide, the initial extremity of which is placed on the 
side of the neck, and fixed by one or two circulars 
of the neck, loosely applied ; making them, for ex- 
ample, from behind forwards, and from left to right. 
Next, direct the roller as it comes from tJie left side 



FIGURE OF 8 BANDAGES. 



77 



of the neck, over and behind the right shoulder, so as 
to confine any dres- 
sings that may be re- Fig. 54. 
quired either there 
or in the axilla ; 
then come up in 
front and over the 



shoulder, and round 
the neck to the left 
side, following the 
same course, and 
covering by each 
turn only one-third 
of the preceding 
turns, so as to make 
a figure of 8, one 
turn of which shall 
embrace the neck, 
and the other the 
axilla. 

Uses. — This bandage will prove useful in retaining 
dressings before, behind, or above the shoulder ; or 
in the axilla ; or at the base of the neck, as it is easily 
applied, and if not drawn too tight, does not restrain 
the motions of the arm. It may also be made with 
a double-headed roller, if the body of the bandage 
is applied under the axilla, and the heads crossed 
upon the shoulder of the opposite side, and then 
brought round the neck to cross on the shoulder and 
axilla of the injured side. It is firmer, as thus ap- 
plied, than the single-headed roller, but may press 
too much on the armpit, and interrupt the circulation, 
or cause cramps in the hand, if care is not used in its 
application. 




THE CROSSED OF ONE BREAST, 

Requires a roller, eight yards long by two and a-half 



78 



THE CROSSED, OR 



inches wide, and that the Surgeon should stand in 
front and on the outside of the limbs of the patient, and 
not in front of her knees, or behind her back, as this 
becomes awkward in the last turns of the bandage. 
In applying it, fix the initial extremity of the roller 
behind the shoulder of the affected side, say the right, 
then carry it obliquely across the back, over the op- 
posite shoulder, and descend on the front of the chest 
to pass from before backwards and under the breast 
and axilla of the injured side. Fix by this turn the 
initial extremity of the roller, and go over the same 
course once or twice, so as to form two or three ob- 
liques of the neck and axilla. Then, on coming to 
the axilla of the diseased breast the third time, direct 

the roller transversely 
Fig. 55. across the back, to 

the axilla of the op- 
posite or left side, and 
return by a horizontal 
turn in front of the 
chest, to the point of 
departure, in order to 
commence another 
oblique of the neck 
and axilla. Continue 
thus making obliques 
of the neck, and hori- 
zontal turns of the 
body, each turn as- 
cending and cover- 
ing in one-third of 
the preceding one till 
the rolleris exhausted, 
when we shall find that the breast is firmly slung, or 
supported by the oblique turns, and compressed by 
the circular ones (Fig. 55.) 

Use. — This bandage is not only useful in retaining 
dressings to the breast, but also in supporting the 




FIGURE OF 8 BANDAGES. 79 

breast itself, when requisite, as in cancer, lacta- 
tion, &c., as it very readily keeps its place, unless 
handled, for thirty-six hours. It may, however, be 
supplanted, in cases of simple dressing, by the sling 
of the breast, as described hereafter, if it should be 
requisite to change the dressing twice or thrice a-day, 
as we shall thus save the fatigue of a re-application 
of the bandage. 

THE CROSSED OF BOTH BREASTS, 

Having more surface to travel over, requires a roller, 
twelve yards long, and two and a-half inches wide. 

Fig. 56. 



rolled either into one or two heads ; or, if the patient is 
very large, it may require a roller of fifteen yards. In 
order to apply it, carry the initial extremity of a single 



80 THE CROSSED, OR 

headed roller behind the right axilla ; thence by cross- 
ing the back, direct the cylinder over the left shoulder ; 
pass obliquely across the front of the chest ; under the 
right breast, and under the right axilla to the point 
of departure. Make thus, two or three obliques of 
the neck and axilla, covering in the breast by the 
gradual ascent of each turn, and on reaching the back 
of the right axilla in the third turn, pass transversely 
across the back, to the left axilla ; under this and across 
the chest in front of the left breast to the right side 
of the neck ; thence across the back to the left 
axilla. Make thus two obliques of the neck and 
this axilla, and on coming to the front of this armpit, 
pass transversely under both breasts to the right 
axilla, and under this to the point of departure, 
taking care that each revolution covers successively, 
the breasts from below upwards, without being drawn 
too tight. If the course here laid down be rigorously 
followed, we shall have an oblique of the neck and 
each axilla, with horizontal turns before and behind, 
and the turns of the roller will be found to mould 
themselves with great accuracy to the roundness of 
the breasts, and thus make gentle and equable pres- 
sure on them ; a point of some importance in certain 
cases of mammary abscess. 

Use. — This, like the preceding bandage, is em- 
ployed to support or compress both breasts, and is 
exceedingly useful in patients who are annoyed by 
pendulous mammae during lactation, &c. It may 
however be as well made by means of a double- 
headed roller, if desired. In this case, place the 
body of the bandage in front of the sternum, and 
carry each cylinder under its respective axilla, to 
form an oblique of the neck and axilla, crossing on 
the back. After one or two obliques, carry one cy- 
linder horizontally in front of, the other horizontally 
behind the chest, to make a half transverse turn, and 



FIGURE OF 8 BANDAGES. 81 

then make other oblique and semi-transverse turns 
of the body, till the whole is covered in. 



THE SPICA OF THE GROIN, OR FIGURE OF 8 OF THE 
PELVIS AND THIGH, 

Requires a single-headed roller, eight or ten yards 
long, three inches wide, and compresses, if required. 

Fig, 57. 




Having arranged the dressing, place the initial ex- 
tremity of the bandage above one of the iliac crests, 
and make two horizontal circular turns around the 
pelvis, in order to fix the point of the bandage, turn- 
ing from right to left, and from before backwards, if 
for the right groin, and the reverse if for the left. 
Arriving in front of one of the groins, say the right, 
descend to the inside of the thigh, between it and the 
genital organs, and winding round the back part, as- 
cend on the outside, to cross the first turn ; thence to 
the iliac bone of the opposite side ; across the back 
and round the pelvis, to follow the same course until 
6 



82 



THE CROSSED, OR 



the cylinder is nearly exhausted, when it should be 
fixed by a circular turn of the pelvis. 

Use. — This is an excellent bandage to retain 
dressings, or make compression on buboes, venereal 
ulcers, abscesses, &c., situated at the groin. If it is 
intended to make a Spica Ascendens, the first turn over 
the groin should go as far down the thigh as the point 
we wish to cover by the bandage, and each turn, co- 
vering in only one-third of that which preceded it, 
should be made to mount gradually upwards. If, on 
the contrary, we wish to make pressure from above 
downwards, the first turn should cross the groin high 
up, near the abdomen, and each subsequent turn de- 
scend, so as to form a Spica Descendens. 

This bandage by covering the groin, is exceedingly 
useful after operations for hernia, or in other cases of 
hernia where compression is required, and a truss 
cannot be borne, or obtained. 

THE SPICA OF BOTH GROINS, 

Is formed by a single-headed roller, twelve yards 

Fi^. 58. 




long, and two and a-half or three inches wide ; two 



FIGURE OF 8 BANDAGES. 83 

horizontal turns of which are first made about the 
pelvis, going, for example, from right to left and 
from before backwards. Upon arriving at the second 
turn, near the left groin, the head of the roller is 
made to pass obliquely downwards along the outer 
side of this thigh, and to ascend along its inside so 
as to cross the first descending turn ; after which it is 
conducted round the back of the pelvis as far as the 
right groin, and passing hence along the inner side of 
this thigh, remounts on its outer side, and is carried 
again round the pelvis in front, and to the left ; the 
head of the roller being then made to pursue the 
course just indicated, until only a sufficient quantity 
remains to terminate the bandage by two horizontal 
turns of the pelvis. 

Use. — Same as the former, but for both groins. 

The Spica of both groins may be very advanta- 
geously made with a double-headed roller, if the body 
be applied to the front of the abdomen, in a line with 
the crests of the ilia, and each head carried around 
them, to cross behind the back and come round on 
each groin. Then let each head descend in the line 
of the groin, between the genitals, on the inside of 
each thigh, and pass under, behind and on the out- 
side of them, to run, one to the right, the other to 
the left ihac crest, and thence round the back, to fol- 
low the same course. 

No bandages can be firmer or simpler than these 
Spica bandages, where it is requisite to make firm 
compression on each groin, but otherwise they will 
prove inconvenient, from the difficulty consequent on 
moving the patient under the circumstances in which 
they are most generally required. For a more simple 
bandage, see the triangular T of the groin. 

THE FIGURE OF 8 OF THE ELBOW, 

Is made of a roller, two yards long and two or two 



84 



THE CROSSED, OR 



and a-half inches wide, by placing the initial extre- 
mity on the external 
Fi^. 59. and upper part of the 

forearm, and passing 
obliquely over the bend 
of the arm to the in- 
ternal tuberosity of the 
humerus ; round and 
above the olecranon to 
the external tuberosity ; 
thence obliquely across 
the front, crossing the 
first turn like an X, to 
the inner and upper 
part of the forearm, and 
then across the back to 
the point of departure, to run the same course. If the 
arm is much flexed, make one circular over the point 
of the elbow, after the formation of the second figure 
of 8. 

Use. — This little bandage is very useful in cover- 
ing in the elbow-joint, when the arm is either flexed 
or extended, and is therefore added to the Spiral of 
the Upper Extremity for this purpose. It is also fre- 
quently employed to retain the compress used after 
bleeding, as may be seen in Fig. 59. 




THE FIGURE OF 8 OF THE WRIST, 

Is made like the preceding, by taking one or two cir- 
cular turns around the wrist, either on its dorsal or 
palmar face, to fix the end of the bandage, then on 
reaching its cubital side, run obliquely across to 
the space between the thumb and forefinger, say of 
the right hand ; then obliquely over the palm to a cor- 
responding point on the metacarpal bone of the little 
finger ; hence obliquely across the back of the hand to 
the wrist-joint ; thence make a semi-horizontal turn 



FIGURE OF 8 BANDAGES. 85 

around the wrist to the ulnar side; run the same 
course over again, as seen in the Spiral of the Upper 
Extremity. 

Use. -^To cover in and compress the wrist-joint. 
It is also added to the Spiral of the Upper Extre- 
mity, in order to cover in this joint. 



THE SPICA OF THE THUMB, 

Is made by a roller, three yards long and a finger's 
breadth wide, of which the initial end is fixed upon 
the wrist by two or three circular turns; after the last 
turn, which should terminate upon its radial side, 
direct the head 

of the roller from ^^S"- 60. 

the external to 
the internal side 
of the thumb ; 
pass between this 
and the index fin- 
ger ; return and 
cross the base of 
the thumb, and 
carry it onward 

again, about the wrist. Repeat these double ob- 
liques and cover in about two-thirds of each turn, by 
the subsequent one, so as to form a spica, until the 
whole of the bandage is exhausted. 

Use. — This bandage will be found very useful in 
retaining dislocations of the first metacarpal bone of 
the thumb, or for making pressure on its top. 

THE FIGURE OF 8 OF BOTH THIGHS, 

Requires a few turns of a roller, two and a-half inches 
wide, in the ordinary figure of 8, so as to keep the 
thighs together, as after the operation of lithotomy, 
or after the reduction of a dislocation of the femur. 




86 



THE CROSSED, OR 



THE FIGURE OF 8 OF THE KNEE, . 

Requires a roller two and a-half inches wide, of 
which the initial extremity, is to be fastened by one 
or two circulars below the knee ; then pass obliquely 
over the patella, say from the outside to its inside ; 
make a semi-horizontal turn on the back of the thigh, 
above the joint, to reach the external condyle ; go 
thence obliquely over the patella to the inner side of 
the tibia ; pass round behind it, to the head of the 
fibula, and run the same course again till all is co- 
vered, as seen in the Spiral of the Lower Extre- 
mity. 

tlse. — To cover in the knee, or compress the joint 
in various cases. It is also added to the Spiral of the 
Lower Extremity, in order to cover in this joint, and 
is used in fracture of the patella. If it is wished to 
retain a dressing to the popliteal space, we have only 
to reverse the turns of the bandage, that is, start it 
by circular turns from within, outwards, and cross 
from below the knee behind, to above it in front. 

THE FIGURE OF 8 OF THE ANKLE AND INSTEP, 

Is made by a roller, two and a-half inches wide, and 

of the ordinary length. 

If in the right foot, place the initial extremity above 

the external malleolus, and make two circular turns 
to fix it ; then on coming to the 
external malleolus on the se- 
cond turn, pass obliquely over 
the front of the instep to the 
tarso-metatarsal articulation of 
the big toe; thence under the 
sole of the foot to the outside ; 
horizontally over the instep to 
the same point, and then pass 
obliquely over to the external 
side of the os calcis ; over this 

side of the bone, and round its point, up on its in- 



Fi^. 61. 




FIGURE OF 8 BANDAGES. 87 

side to cross the anterior extremity of the astraga- 
lus ; over the upper part of the instep ; down the 
outside ; at the point of the cuboid bone ; under the 
sole to the inside of the calcis ; around its point to the 
outside, and up over the instep to the point where 
the cuneiforme internum is placed, and thence follow 
a similar course till the heel is covered in, which is 
generally done in two turns and a-half of figures of 
8. To cover in the extreme point of the heel, be 
careful that each turn that goes over the sole, is kept 
as much backwards towards the point of the heel as 
possible, as the bandage will not slip off, if drawn 
moderately tight. If it is not necessary to cover in 
the heel, the turns may be made as in the figure. 

Use. — This bandage may be resorted to where we 
wish to retain dressings to the heel, instep, or front 
of the ankle-joint, as in excoriations from the extend- 
ing band of the apparatus for fracture of the thigh. 
It is also added to the Spiral of the Lower Extre- 
mity, when we wish to cover in the heel, as well as 
the whole limb, as in the Compressing Bandage. 



RIBBAIL'S BANDAGE, 
OR THE SPICA OF THE INSTEP, 

Js a neat bandage, made of a single-headed roller, 
seven yards long and two inches wide, by laying the 
initial extremity of the roller on the tarsal end of the 
metatarsal bone of the little toe, if in the right foot, or 
on that of tie big toe, if in the left. Then passing 
obliquely over the front of the foot, to the first joint of 
the big toe in the right foot, or that of the little toe if 
in the other, go under the sole of the foot horizontally, 
in a line with the metatarso-phalangeal articulation, to 
the outer or inner side of the foot, according as it is 
the right or left. From this point, make two obliques 
over the front of the foot, which will bring us to the 
instep on its inner or outer side, and then pass di- 
rectly to the point of the heel in a line, parallel with 



88 THE CROSSED, OR FIGURE 8 BANDAGES. 

the sole of the foot, the edge of the roller projecting 
a little beneath the sole ; thence around the heel to 
come to the instep again, keeping still parallel with 
the sole of the foot ; cross the instep and make an- 
other turn similar to the first, which shall embrace 

Fi£: 62. 




the heel and instep, cover in one-third of the preced- 
ing turn, and form a spica on the instep (Fig. 62.) 
Continue these turns, gradually ascending, till the foot 
will hold no more, when we may terminate the ban- 
dage by circular turns above the ankle, or else form 
a spiral up the limb. 

Use. — This forms a most excellent bandage for 
cases requiring firm compression of the instep or an- 
kle, as in wounds of the anterior or posterior tibial 
arteries at these points, and is at the same time ex- 
ceedingly neat in its appearance. The figure shows 
the best position of the limb of the patient and of the 
surgeon. For it, as well as for many other practical 
details, I am indebted to M. Ribbail, of Paris, from 
whose excellent course on Minor Surgery, much that 
is of daily service has been gained. 

The Figure of 8 of the Toes, or the Spica of the 
Big Toe, is so precisely similar to these bandages in 
the fingers and thumb, as not to require a repetition. 
In applying any of them, make a few circulars of the 
instep instead of the wrist, and then proceed exactly 
as in the hand. 



THE KNOTTED BANDAGES. 



89 



CHAPTER IV. 

OF THE KNOTTED BANDAGES. 

These bandages named from their making a knot like 
that known as the Packer's Knot, are formed of double- 
headed rollers, and intended to make firm compression 
on particular points, as on bleeding vessels, &c. T.he 
only one of them of any importance, is that of the head, 
used for arresting hemorrhage from the temporal artery, 
though under the same class, we might include all 
those which are terminated by bow-knots, as in the 
8 of the elbow after bleeding at the bend of the arm ; 
that of the ankle, as well as the Sailor's Knot, Clove- 
hitch, and others employed in the treatment of Dis- 
locations. 



THE KNOTTED BANDAGE OF THE HEAD, 

Is made of a band, five yards long and two inches 
wide, rolled up into two 
heads of unequal size, one J^ig- 63. 

being a fourth larger than 
the other, by placing the 
body of the bandage over 
the graduated compress 
covering the wounded ar- 
tery, and conducting the 
two heads one before, and 
the other behind, to the op- 
posite temple, where we 
reverse them in order to 
return to the point of de- 
parture. Now givethem a 

turn or twist, so as to enable us to carry one over the 
summit of the head, and the other underneath the chin, 




90 THE KNOTTED BANDAGES. 

to the sound side, and when they meet, reverse them 
as in the first instance ; from thence they are to be 
conducted in the same course, to the point of depar- 
ture on the wounded vessel. A second twist being 
effected, conduct them for the third time to the op- 
posite temple, and for the third time also, return hori- 
zontally and knot them firmly, each knot being 
placed behind the one first formed ; the roller being 
then conducted, the one head over the vertex, and 
the other underneath the chin, is terminated by a 
few circular turns of the forehead and occiput. 

Use. — For arresting hemorrhage of the temporal 
artery, or any of its branches. It is, however, a pain- 
ful bandage, from the compression made on the 
lower jaw and point of injury, and requires attention, 
in order that it shall not remain on too long, or be 
too tight. It is useful to close the opening in the 
vessel first, with a piece of adhesive plaster, as will 
be seen hereafter when treating of Arteriotoray. 



THE RECURRENT BANDAGES. 91 



CHAPTER V. 



OF THE RECURRENT BANDAGES. 

These are formed by convolutions or parabolic and re- 
current turns, which make a kind of cap for the parts 
to which they are applied. Unlike most caps, how- 
ever, they are exceedingly apt to become relaxed, 
and although very neat in their appearance, require 
more watching than is convenient, and are therefore 
often supplanted by other dressings. When re- 
quired, they may be made either with the single or 
double-headed roller ; but from the difficulty of re- 
moving the latter without its coming off in mass, and 
thus perhaps bringing ligatures, &c., altogether, that 
formed by the single-headed roller, is the one most 
generally employed. 

THE RECURRENT OF THE HEAD, 

Is composed of a single-headed roller, five yards 
long and two inches wide, of which the initial extre- 
mity is placed on one side of the head on a line with 
the supra-orbitary ridge, and the cylinder carried 
two or three times round the head by circular turns. 
On coming to the middle of the forehead in the 
second turn, the bandage is reversed and the re- 
verse confined with one hand, while the cylinder is 
carried over the top of the head in the line of the 
sagittal suture, to the occipital protuberance, re- 
versed here, and the reverse held by an assistant. 
Then come obliquely over the head to the forehead ; 
make another reverse to go to the occiput, each turn 
covering in one third of the preceding one, and con- 
tinue thus, till we reach the horizontal turn On the 



92 



THE RECURRENT BANDAGES. 



right or left side of the head. Cover in the opposite 
side by similar turns, seeing that each reverse comes 
to the same point, in front and behind, and terminate 

Fig. 64. 




the bandage by circular turns, firmly applied around 
the terminations of the reversed turn, as in Fig. 64. 

Use. — To retain dressings to the head, as in the 
application of blisters to the scalp — in erysipelas, in 
wounds, and in other injuries of the scalp, &c. 
Care, however, must be taken not to draw the hori- 
zontal turns too tight, lest, as in the case related by 
Percy, ulceration or gangrene ensue. 



THE RECURRENT OF THE HEAD, 

As made by a double-headed roller, requires the body 
of the bandage to be placed upon the occiput or fore- 
head, and after two or three circular turns, the rol- 
lers be made to intersect each other upon the occiput ; 
one of them is then reflected over the vertex to the fore- 



THE RECURRENT BANDAGES. 



93 



head, and the other continued in a circular course on 



Fig. 65. 




the side of the head. Then 
crossing each other upon the 
forehead, the first head is car- 
ried obliquely backwards to 
the occiput, and reflected by 
the side of the other. The 
last, a, is continued in a cir- 
cular direction, but the first, 
6, is again brought over the 
head, from behind forwards, 
and carried in this way back- 
wards and forw^ards, in re- 
verses, till the head is entire- 
ly covered. 

Use. — This, like the pre- 
vious bandage, serves to confine dressings upon the 
head, but is now rarely employed for the reasons 
stated. The ancients exerted, by its means, compres- 
sion on the heads of Hydrocephalic patients. 

THE RECURRENT OF AMPUTATIONS, 

Embraces two varieties, according as it is made with 
a single or double-headed roller. As, however, it is 
difficult to remove the latter, I shall onJy give the 
application of the former, which is made of a single- 
headed roller, of different lengths according to the 
volume of the stump to be covered, but generally 
only two, or two and a-half inches wdde. 

The position of the patient, for the application of 
this bandage should be such as is most easy to him, 
with the stump well supported and the integuments 
pushed over the end of the bone, by assistants. 

Then having arranged the Malteese Cross and other 
dressings, place the initial end on the surface of the 
limb, three or four inches above the extremity of the 
stump ; make two or three circular turns to fix it, and 
on coming to the central point of the under portion 



94 



THE RECURRENT BANDAGES. 



of the limb, reverse the roller, so as to run up in 
front of the stump and over its upper surface to a point, 
A, (Fig. 66) four or more inches above its extremity. 
Fix all these reverses by the fingers of one hand, if the 



Fis. 66. 




size of the limb will permit; if not employ an assistant 
for the reverses on one side, and continue to make 
them till the whole face of the stump is covered, when 
we terminate itby spiral reversed turns, which, starting 
from the circumference of the stump, B, runs up a 
few inches above the first turn of the bandage, where 
it is to be confined by a pin. If there is a tendency 
to spasm of the stump, the ends may be carried on 
and fixed fast to the pillow or bed on which the 
limb lies, and will thus prevent its jumping; but 
care is requisite not to draw the recurrent turns 
at A too tight, lest, by compressing the soft parts 
against the point of the bone, they cause this irri- 
tation and spasm. 

This figure also show^s the application of a Sus- 
pensory Bandage, to the Testicles. 



COMPOUND BANDAGES, ETC. 



95 



CHAPTER VI. 

OF THE COMPOSITION AND APPLICATION OF 
THE COMPOUND BANDAGE, OR THE BANDAGE 
PROPER. 

It has been already stated, that usage had justified 
the application of the term Bandage, to what should 
be strictly known only as the Roller, and that we 
should therefore designate, the Bandage proper, under 
the head of Compound Bandages. 

These include a considerable number of our most 
useful means of retaining dressings, and their ap- 
plication is generally very simple, though their com- 
position is sometimes a little complicated. To the 
latter, therefore, we shall pay the most attention, be- 
lieving that after their construction, their application 
will be simple enough. 



THE SINGLE T, OR CRUCIAL BANDAGE, 

Named from its shape, is composed of a horizontal 
portion, of a length sufficient to go entirely round the 
part to be covered, and 
yet leave enough to ^^o-. 67. 

make a bow-knot, and 
of a vertical piece, 
which is half the length 
of the horizontal one, 
and generally attached 
firmly to its middle, so 
as to form the perpen- 
dicularportionoftheT. 
(Fig. 67.) Each por- 
tion should be rolled 



96 



COMPOUND BANDAGE, OR 



into a 



Fig. 68. 



cylinder, and confined by a pin previous to its 
application, in order to ensure 
its smoothness when applied. 

The vertical portion varies 
considerably in its shape and 
length. Sometimestherearetwo 
vertical pieces, as in the Double 
T ; and sometimes it is three 
or four inches wide, and slit 
into two tails to within a short 
distance of the horizontal band, 
as in Figure 68. At others a 
triangular piece is added, &c., 
&c., as will be seen hereafter 
in the special applications of 
this bandage. 




THE T BANDAGE OF THE HEAD, 

Requires a horizontal piece of bandage, two yards 
long and two inches wide, upon which, at about one- 
third of its entire length, a strip half a yard long 
and of the same width, is stitched at right angles 



Fig. 69. 



to form its vertical portion. 
The bandage is then rolled 
into two heads previously to 
its application, and the sur- 
geon placing himself before 
the patient, applies the body 
of the bandage to the middle 
of the forehead , with the edge, 
corresponding to the verti- 
cal portion of the bandage, 
uppermost, in order that the 
latter, after traversing the ver- 
tex, may hang loosely down 
the nape of the neck. He then 
passes the remainder of the horizontal portion along 




BANDAGE PROPER. 97 

the temples to the occipital region, where they cross 
the vertical strip, which should be immediately re- 
flected upwards, and secured upon the brow by the 
last turns of the horizontal portion. A double T, 
may be formed by simply stitching a second strip 
upon the transverse portion of this, at a convenient 
distance from the first. 

Use. — This light bandage, maybe used for retain- 
ing dressings to the scalp when the vertical band is 
so placed that it may run over the point to be covered 
in, and where the dressing is small, is preferable to 
the recurrent bandage of the head, as it is not so 
heating. If likely to be deranged by slipping up- 
wards, a band may be added, which shall pass under 
the jaw. 

THE T BANDAGE OF THE EAR, 

Is made of a horizontal portion, two yards long, of a 
vertical one, a half yard in length, and of a piece of 
linen of the shape and size of the external ear. Sew 
the horizontal band 
to the summit of the ^^' ' 

ear-shaped piece of jl^ rfl^J! 

muslin, and attach the '*^ffiL— 
vertical one, to the 
opposite part, or that 
corresponding with 
the soft part of the ear. 
Then place the cir- 
cular band around the 
head, over the ear of 
the affected side, and 
the muslin over or 

close behind the ear ; then carry the vertical band under 
the jaw and up on the opposite side, where it will be 
confined by the horizontal turns. 

Use. — This modification of the T, is an excellent 
bandage for retaining dressings to, or behind the ear, 
7 




98 



T BANDAGES. 



especially the latter. Every one has felt the difficulty 
of retaining blisters or dressings to this part, but the 
construction of this little bandage removes it entirely. 
If made of black silk and narrow ribbons, it would 
hardly be noticed in persons wearing whiskers, or in 
those wearing caps or bonnets. 



Fls-. 71. 



THE DOUBLE T OF THE NOSE, 

Is made of a band, one inch wide and two yards long ; 
of two other bands of the same width, but one yard 
long, the latter being sewed on the former, so that 
they may be one inch apart, and at right angles to 
the first band. After this the transverse band should 
be placed upon the upper lip, with the border to 
which the vertical bands are attached, turned upwards, 
and the two extremities being carried over each 
cheek, and under the ears to the nape of the neck, be 
there held by an assistant. Then cross the vertical 
bands upon the root of the nose, and carry each one 

over the parietal protuber- 
ance of its side, and down 
to near each mastoid pro- 
cess, under the horizontal 
band. Turn them over this 
to come upwards, and fix 
them by bringing the re- 
mains of the horizontalband, 
from its crossing on the nape 
of the neck, round the fore- 
head ; where they may be 
fastened either by a knot or 
a pin. 

Uses. -^This little band- 
age is very useful in retain- 
ing dressings to the upper 
lip and root of the nose, especially in cases of fracture 
of the bones of the latter, or in epiphora, or fistula- 
lachrj-malis, as it is easily renewed, and does not 




T BANDAGES. 



99 



interfere with the use of the eyes, nose, or mouth ; 
whilst it acts on the part nearly as firmly as adhesive 
plaster, without being liable to its objection. 

The single T bandage of the nose is also a useful 
one in retaining dressings to its surface, but as it is 
much improved by the addition of a suspensory, it 
will be treated of under the latter bandages. 



Fig. 72 



THE DOUBLE T OF THE CHEST, 

May be formed of a broad piece of muslin, and of 
a band two feet long, split nearly to the end ; or of 
two distinct bands of the same length, w^hich are to be 
attached to its upper edge. Then pass the mus- 
lin around the chest 
and bringing the two 
extremities forwards, 
stitch them to the first 
piece ; or the bands 
themselves may be 
brought forward over 
each shoulder, and se- 
cured in front, so as to 
form shoulder-straps. 
Fig. 72. 

Use. — In cases of 
fractures to compress 
the ribs, or to retain 
dressings to the back. 

Frequently buckles and straps are fastened to the ends 
in front, and buttons to the upper edge to receive the 
shoulder straps; these make the bandage much firmer, 
but also a little more complicated in its composition. 

THE DOUBLE T OF THE ABDOMEN, 

Consists of a piece of muslin, to one of the borders, 
of which, are stitched at equal distances from its centre, 
two narrow bands half a yard long, to serve for thigh 




100 



T BANDAGES. 



or perineal straps. They should be attached sufficiently 
apart to correspond with the great trochanters. 

In its application, the middle of the muslin should 
be placed around the pelvis, and the extremities 
brought round, on the abdomen, where they over- 
lap and pin ; the vertical bands are then conduct- 
ed from behind forwards, crossed under the peri- 
neum, and fixed upon the forepart of the horizontal 
band. 

Use. — To retain poultices or other dressings upon 
the abdomen; to exert compression on this part after 
the operation of paracentesis, or after delivery, al- 
though its application then belongs rather to the ac- 
coucheur, than to the surgeon. 

This is the T of the chest reversed, the vertical 
bands being made to pass under the pelvis instead of 
over the shoulder. 



THE TRIANGULAR, OR COMPOUND T OF THE GROIN, 

Requires a piece of muslin, four inches wide at 
its base, and ten inches long, made of a trian- 
gular shape, in order to 
Fig. 73. correspond with the up- 

per and internal part of 
the thigh. To the base 
of this, is sewed a hori- 
zontal band, about a 
yard and a-half in length ; 
and to its summit, a ver- 
tical one, three-quarters 
of a yard long. 

The dressings being 
then placed on the part, 
the extremities of the 
horizontal band are car- 
ried round the pelvis on 
either side as far as the sacrum, whence they are re- 
turned and tied in a bow, above the pubes, whilst 




T BANDAGES. 



101 



the vertical band, and the triangular piece passing 
down between the thigh and scrotum, the former 
comes up over the outside of the thigh, and is attached 
to the transverse portion of the bandage. 

Use. — To retain dressings upon the groin of a 
patient confined to bed, as in poulticing buboes, 
or after operating for hernia, and is one of the best 
bandages that we can employ for retaining dressings 
to the groin, when it is requisite to renew them fre- 
quently, especially where it is difficult to move or 
raise the patient ; as it is only necessary to untie the 
vertical band and draw it from under the thigh, in 
order to lay open the whole groin to our view, which 
may be readily done without the least movement on 
his part. 

THE DOUBLE T BANDAGE OF THE BUTTOCK, 

Requires a roller, two yards long, and three inches 
wide, and also two verti- 
cal bands, each half a yard ^^S"- '^4. 
in length, and two inches 
broad, stitched to it at 
right angles, at about one- 
fourth of its length. Then 
the horizontal band being 
placed around the pelvis, 
so that the vertical bands 
may correspond to the me- 
dian line of its posterior 
face, its extremities are fixed 
with pins, and the vertical 
bands brought under the perineum, and fastened to 
its front portion. 

Use. — This is the common double T bandage, em- 
ployed to retain dressings to the perineum, anus, or 
vagina, in cases of piles, prolapsus ani, and fistulse. 
Instead of the two tails, that, formed by slitting the 
single T may be used, as seen in Fig. 68. 



mn 



102 



T BANDAGES. 



THE T BANDAGE OF THE HAND, 

Is composed of a narrow bandage or piece of tape, 
one inch wide, half a yard long ; and of a second 
piece, one yard long. Sew the longest piece to the 
other, in order to form the vertical portion of the T, and 
place the horizontal band on the back or front of the 
wrist, so that the vertical band may present to the 
fingers. Carry the latter over the back or front of the 
hand, over the inter-digital space of the first and second 
finger ; come up again to the wrist, and surround it 
by a half turn of the horizontal one ; reverse the first 
over the latter to return to the space between the 
middle and third finger, retaining the dressing, and 
coming up to the wrist again ; surround it again by 
the horizontal band ; reverse the vertical one in order 
to pass between the ring and little finger, and on the 
outside of the latter to the wrist, where it may be 
fastened by the turn round the joint. 

Use. — This is a very light bandage for retaining 
dressings to the inter-digital spaces, as well as the body 
of the hand, and offers a substitute for the gauntlet or 
demi gauntlet, before seen. 

THE PERFORATED T OF THE HAND, 

Is made of a two inch roller, one yard long, and of a 

piece of muslin of the 
J^'S"' 75. breadth, and twice the 

length, of the palm of 
the hand. Fold the 
muslin on itself in its 
length, and cut in it 
four circular openings, 
as at D, about three 
lines apart, to corres- 
pond with the fingers ; 
then sew one of its ex- 
tremities at right angles 

to the roller or horizontal band, as in Fig. 75. 




T BANDAGES. 103 

Pass the fingers through the openings, and stretch 
the muslin over the back and front of the hand, con- 
fining the loose end by a few circular turns of the 
roller around and above the wrist. 

Use. — Same as the above. 

The T bandages of the Feet being similar in their 
formation and application to the above, do not require 
a special consideration. 



104 INVAGINATED, OR 



CHAPTER VII. 



OF THE INVAGINATED, OR SLIT AND TAIL 
BANDAGES. 

These might be classed under the Uniting Bandages, 
as the general object of their application is to bring 
separated parts into contact, did not usage place them 
under the Compound Bandages. 

OF THE INVAGINATED BANDAGES. 

There are two kinds, which we shall now treat of; 
one, in which the same roller is formed at one end 
into strips or tails, and at another part, into slits or 
button-holes, and the other, in which two distinct 
bands are thus prepared. In either case, the tails 
of one part are passed through the openings in the 
other, and by acting on compresses, approximate 
all the portions under them. The first is employed to 
assist the union of longitudinal, the other of trans- 
verse wounds, as well as in the the treatment of certain 
fractures. When wounds are deeply seated, the appli- 
cation of adhesive strips only unites the surface and 
leaves the parts below separated, so that, as the 
secretion of pus goes on, a bag or cyst is formed, 
from which it cannot escape except, by burrowing 
underneath. When, also, divided parts have a ten- 
dency to contract, they very frequently tear out the 
stitches, and it is in both these cases, that these ban- 
dages will be found exceedingly useful. 

THE INVAGINATED BANDAGE, FOR VERTICAL WOUNDS 
OF THE LIP, 

Is composed of a roller, two or three yards long and 
one inch wide, rolled into two heads ; and of two 
small compresses about two inches square, w^hich 
are to be placed on the cheeks near the angle of the 
mouth. 



SLIT AND TAIL BANDAGES. 



105 




In applying it, place the body of the roller on 
the forehead, or on the nape of the neck near the 
occiput, and carry each head round under the lower 
part of the ear, over 
the malar bones, and -fV- '^^^ 

over the compresses 
to the lip. Then slit 
in one bandage a hole 
large enough to admit 
the other head ; pass 
it through and draw 
upon each roller ; car- 
ry them both round 
to the neck, and then 
run the same course 
till the parts are well 
supported and cover- 
ed in, as in Fig. 76, 
terminating on the forehead. 

Use. — In vertical wounds of the lip where other 
means are not at hand, or to support the hare-lip suture 
and prevent its cutting out. By the pressure which 
.it makes on the lip, it is also useful in arresting he- 
morrhage from the corronary arteries. 

THE INVAGINATED OF THE BODY, 

Is made by a double-headed roller, of a length sufficient 
to go several times round the body, and of two com- 
presses of the length of the wound, the body of the ban- 
dage being placed on the back, and the heads brought 
round under each axilla, and over the compresses on 
each side of the wound. Then make a slit in the body 
of one side, and pass the cylinder of the other side 
through it, by which means the w^ound will be well 
closed. Continue this as often as may be necessary. 
Use. — To unite Longitudinal Wounds of the chest 
or abdomen, or to support the parts after the removal 
of the breast. 



106 INVAGINATED, OR 

THE INVAGINATED BANDAGE FOR LONGITUDINAL 
WOUNDS OF THE EXTREMITIES, 

Is made of a piece of linen, sufficiently long to 
make three or four turns of the part to be treated, 
and of a breadth correspondent to the length 
Fig. 77. of the wound. This is, to be divided so as 
to form three tails, long enough to em- 
brace three-fourths of the part wounded. 
At a convenient distance further on, three 
longitudinal perforations, are made oppo- 
site to, and of the same breadth as the tails. 
The remainder of the band is then rolled 
up, and two graduated compresses made, 
of such a size as may be required by the 
wound. 

If the bandage is to be applied to the 
upper portion of the limb, its lower part 
should be first covered by the turns of the spiral ban- 
dage, and then the undivided portion, or that situated 
between the tails and the slits, being applied upon the 

part which is ex- 
Fig.iQ actly opposite the 

wound, and the 
graduated com- 
presses placed 
on each side of 
the latter, at the 
distance of about 
three or four 
fingers' breadth 
from its edges, 
the tails are to be passsed through the corresponding 
slits, and the edges of the wound united by draw- 
ing the extremities of the bandage in contrary direc- 
tions ; after which the tails are secured by the turns 
of the remainder of the roller, or by those of a 
Spiral one. 

Use. — This bandage may be used in deep-seated 




UNITING BANDAGES. 



107 



wounds of the extremities, as an adjuvant to adhe- 
sive strips, on account of its uniting the deep-seated 
parts as well as the skin, thus preventing any disten- 
sion of the inside of the wound, and the formation of an 
abscess. 

THE UNITING BANDAGE FOR TRANSVERSE WOUNDS, 

Will be referred to under the head of Fractures of 
the Patella. 

THE BANDAGE OF WINSLOW FOR WRY-NECK, 

Requires a roller five yards long and two inches 
Fi^. 79. 




wide, and some cotton or pads to protect the pos- 
terior fold of the axilla from the last turns of the 
bandage. The initial extremity being then placed 



108 INVAGINATED, OR 

just above the mastoid process of the affected side, 
the bandage should be carried thence in front of the 
parietal protuberance of the same side, over the top 
of the forehead, and then around the head by several 
circular turns, so as to fix the initial end, firmly. Now 
placing a pin or two in the turns on the forehead, as 
shown in Fig. 79, pass down behind the axilla of the 
sound side, over the cotton or compresses previously 
placed there, round under the axilla to the front of 
the chest, and see that it is fastened very firmly to the 
clothing of the patient, or to a band placed around 
the chest, the head being drawn well over to this 
side, before the bandage is completed. The turns of 
the bandage on the head, and the obliquity of its 
course, from the forehead, behind the shoulder, round 
to the front of the chest, fulfil the indications of the 
treatment, by overcoming the inclination to the oppo- 
site side and turning the head to the front, thus op- 
posing the action of the sterno-cleido-raastoid muscle 
of the sound side. 

It affords, however, but very slight means of act- 
ing upon the head, and is apt to slip or stretch. 
These objections and better mechanical contrivances, 
have therefore very nearly displaced it, though it is 
occasionally employed as a temporary dressing. 

APPARATUS OF PROF. JORG, OF LEIPSIC, FOR WRY-NECK. 

This consists of a pair of leather stays and of a 
band or fillet which goes round the head. On the, 
centre of the forepart of the stays, is a kind of pulley 
or grooved wheel, which can be turned round with a 
key in one direction but not in the other, as it be- 
comes fixed by means of a spring. From this pulley 
or wheel proceeds a band up the neck, to the fillet on 
the patient's head, to which it is fastened directly 
behind the ear, close to the mastoid process. The 
band lies in the same direction as the lengthened 
sterno-cleido-mastoideus muscle, and when drawn 



UNITING BANDAGES. 



109 



towards the breast by means of the wheel, pro- 
duces the same effect as would arise from an increase 
in the action of that muscle. In short, it pulls the 

Fig-. 80. 




mastoid process downwards and forwards towards 
the sternum, counteracts the opposite muscle of the 
same name, and rectifies the position of the head. 
Professor Jorg makes his patient wear this apparatus 
day and night, nor does he take it off even when the 
contracted rigid muscles are rubbed with the lini- 
ment that he recommends."* 



* Samuel Cooper's First Lines — by Stevens of New York. 



man 



110 



UNITING BANDAGES. 



THE UNITING BANDAGE FOR TRANSVERSE WOUNDS OF 
THE NECK, 

Is very useful in cases of maniacs. It requires a 

Fi^. 81. 




single-headed roller, four yards long ; a piece of 
bandage half a yard long and three inches wide ; 
a bandage for the chest with perineal bands ; and a 
night cap to cover the head. * 

Fasten this on the patient's head by a few turns 
of the roller, and fasten at the same time, the band by its 
centre upon the top of the head. The bandage being 
then applied round the chest and pinned, the band is 
secured by a few more circular turns of the roller, after 
which its extremities are firmly fastened to the fore- 
part of the body, the head being forced down on the 
chest so as to bring the chin near the top of the 
sternum. 



SLINGS, 111 



CHAPTER VIIL 

OF SLINGS. 

Slings are light bandages of great simplicity, and very 
useful in retaining simple dressings, as they do not 
oppress the part to which they are applied. They are 
formed of pieces of muslin of various lengths and 
widths, split at each extremity into two or three tails 
up to w^ithin a few fingers' breadth of their centre, as 
seen in Fig 82. They are also occasionally formed 
of a piece of mus- 
lin of a size suffi- Fig. 82. 
cient to cover the 
part to which the 
dressing is to be 
applied, each end 
having two bands 
attached to it 
to serve as tails ; 

thus making it resemble the slings employed in war 
by the ancients for hurling stones, w^hence their name. 
In using the sling, the body or central part is first 
applied to the part, and the tails carried round it and 
cofifined by knots, or pins. 

THE SLING OF SIX TAILS, OR THE BANDAGE OF GALEN, 

Is made of a piece of muslin, a yard long, and a 
quarter of a yard wide, split at each end, to within 
three finger's' breadth of the centre, into three tails, 
the central tail being somewhat broader than the 
others. The body of the sling being then placed on 
the top of the head, the central tails are passed along 
the ears and secured underneath the chin, the tails 




112 



SLINGS. 




being smoothly folded so as to adapt them better to the 
f-^-^, 83. lower jaw. Thefrontal tails are 

then to be directed from the 
anterior to the posterior part 
of the head, where they should 
overlap each other, while the 
occipital tails are brought for- 
ward, and secured on the fore- 
head by pins, as in Fig. 83. 

Use. — To retain large 
dressings, as poultices, &c., 
to the whole scalp. 



THE SLING, OR FOUR-TAILED BANDAGE OF THE HEAD, 

Requires a strip of muslin, a yard long and six inches 
broad, to be split at each end to within three fingers' 

breadth of the centre. 
Fi^r- 84. When the wound is on the 

forehead, the body of the 
sling is applied there, and 
the two upper tails, carried 
posteriorly, and fixed at 
thebackof the head, whilst 
the lower tails are fas- 
tened either upon the ver- 
tex or beneath the chin, 
as the surgeon may con- 
sider most convenient. 

To confine a dressing 
upon the summit of the 
head, the posterior tails, 
are brought down and se- 
cured beneath the chin ; 
the anterior tails, after being carried to the nape of the 
neck and crossed, being fixed before the throat, or 
brought again on the forehead (Fig. 84). 




SLINGS. 



113 




In applying it to the nape of the neck, the upper tails 
are conducted over the 
forehead, from whence, ^^g- 85. 

after being made to 
cross each other, they 
are returned, and fas- 
tened at the occiput ; 
the lower tails passing 
round the front of the 
neck. This forms the 
sling of the neck, and 
is seen in Fig. 85. 

Uses. — These ban- 
dages are very simple 
and convenient, and 
of great utility in 
wounds of the head 

or neck, as they can be applied over every point of 
this portion, by merely changing its direction. On the 
neck, especially, the sling forms an excellent bandage 
for retaining blisters, setons, &c. 

THE SLING OF THE CHIN, 

Requiresa piece of mus- Fig.^Q^ 

lin,six inches by four, slit 
at each extremity for 
two inches, to each of 
•which is to be attached 
a piece of tape or band- 
age oneyard long. Then 
placing the body of the 
sling under the jaw, so 
that the chin may be ex- 
actly in its centre, carry 
the two posterior tails up 
over the cheeks and ver- 
tex, to the mastoid pro- 
cess of each side, where an assistant holds them. Then 
8 




114 



SLINGS. 



turn the anterior part of the sling and the anterior tails 
upwards in front of the chin, and carry the front tails 
under each ear to the nape of the neck ; cross them on 
the neck to come forwards to the forehead, where they 
may be knotted, after the tails from the mastoids have 
been carried under their posterior portion. 

Uses. — In fracture of thejaw without displacement, 
and to retain dressings to the front of the chin, or 
under the jaw. 

THE SLING OF THE FACE, OR MASK, 

Is made of a body piece to fit the face, and of four 
tails to hold it in its position. 

In forming it, fold a piece of muslin, nine or 
ten inches square, on itself, so as to form an oblong 

square. Place this 
^ig-- 87. on the face so that 

the double side may 
correspond exactly 
with the central line 
of the face, and 
mark on it, a line, 
A B, and a circular 
opening, C, for the 
eyes. Make also a 
semicircular, F, for 
the mouth, and a 
small transverse cut, 
E, to correspond with the end of the nose. Then 
cut off the angles, A H, and I K, so as to give it an 
oval form, and cut out at G, two triangular pieces, the 
edges of which are to be sewed together to adapt it 
to the projection of the cheek bones. Attach two ver- 
tical tails at G, and two horizontal ones at A ; then 
open it out and make a vertical cut, D, from the trans- 
verse line at the point of the nose, up to the point be- 
tween the two eyes, as in Fig. 87. Apply this to 
the face and carry the upper tails to the occiput; 




x^ 


-o 






^i 


V 


:< 



SLINGS. 



115 



cross them ; come round on the forehead, and carry 
the horizontal tails to the neck, in order to return to 
the forehead or chin, as in the same figure. 

Use. — To retain dressings to the whole face, in 
cases of burns from blasting rocks, gunshot-wounds, 
small-pox, &c., in all of which it will be found to be a 
most useful bandage. 

THE SLING OF THE BREAST, 

Is made of a square piece of muslin, sufficiently large 
to cover in the breast, slit for one inch and a-half on 
each of its four sides, and of four bands sewed to its 
four angles. These must be long enough to go 

Fi.^. 88. 




round the chest. Now whilst an assistant supports the 
breast or retains the dressing, place the body of the 
sling on it, and carry the lower tails under each axilla; 



m 



116 SLINGS. 

come round in front of the chest, and carry the upper 
tails on each side of the neck, over the shoulder, and 
fasten them to the horizontal band. 

Use. — To retain a poultice or other dressing to 
the breast, or to support it, as in cases of cancer, &c. ; 
but if compression is required, the Crossed of the 
Breast, answers better. 

This, or the Four- tailed Sling, may also be usefully 
employed in retaining dressings to the point of the 
shoulder ; the elbow ; back and front of wrist ; or to the 
heel and instep. In either of these cases, place the 
point to be covered, in the centre of the body of the 
sling, and carry the tails round the part, so as to fix the 
bandage firmly. 



SUSPENSORIES, SHEATHS, ETC. 



117 



CHAPTER IX. 

OF SUSPENSORIES, SHEATHS, AND LACED BAN- 
DAGES. 



Suspensories are bags of certain sizes, intended to 
support depending parts, retain dressings to them, or 
cover such portions as would not otherwise receive a 
bandage. In all such cases they will be found of 
great service, and as their manufacture is simple, we 
are surprised that they have not obtained a more 
general use. As adapted to the nose we can highly 
recommend them to those requiring a complete band- 
age for such parts. 

THE SUSPENSORY OF THE NOSE, 

Is used to retain dressings to the whole of this 
part, and is com- 
posed of a trian- 
gular piece, cut as 
in the dotted lines 
B C, and C D, of 
Fig. 89, to the sides 
of which are attached 
the vertical and hori- 
zontal bands of a sin- 
gle T. In applying 
it, place the nose 
within the suspen- 
sory, and. carry the 
vertical band over 
the head to the neck, confining it by the horizontal 
bands, which are crossed there, brought up on the 
forehead, and fastened as seen in the cut. The open- 
ing at A is to suit the position of the nostril. 




118 



SUSPENSORIES, SHEATHS, 



Fi^-. 90. 



THE SUSPENSORY, OR BAG-TRUSS OF THE SCROTUM, 

As found in the shops, consists of a network bag and 
bands to fasten it (Fig. 66) ; but as this cannot always 
be had, its place may be readily supplied by one 
formed as follows, the application of both being the 
same. Fold a piece of muslin, on itself, of a size to 
suit the part, say six inches by four, and cut out an 
opening. A, for the penis, and a curvilinear portion 
according to the dotted line, B C. Sew the divided 
edges of this together, and at- 
tach a horizontal band, D, to 
the upper part, and two verti- 
cal ones, EF,to the lower pos- 
terior angle, making an open- 
ing or button-hole in the end 
of each band. Sew on two 
buttons to the horizontal 
band to serve for the attach- 
ment of the vertical or peri- 
neal straps. Then the penis 
being engaged in the opening, 
A, and the scrotum perfectly 
enveloped, the belt should be 
carried round the pelvis ; returned in front, and tied 
above the pubes. The two vertical bands are then 
made to ascend from the perineum along the inferior 
border of the glutei muscles, and buttoned to the 
belt in front. 




Use. — To support and confine dressings upon the 
scrotum ; to serve also for points of attachment to 
other apparatus, and for the treatment of swelled tes- 
ticle, hydrocele, and irreducible scrotal hernia. This 
bandage should always be worn during the treat- 
ment of acute gonorrhoea, as it diminishes the liability 
to Epididymitis. 



AND LACED BANDAGES. 119 

SHEATHS, 

Are coverings intended to retain dressings to the 
penis, fingers, and toes. They are the finger-stalls of 
domestic use, and employed daily by every one who 
has a cut finger. A very useful application of them by 
the surgeon can be made in casesof gonorrhoea, as when 
made of large size, they will readily retain a portion of 
charpie to the head of the penis, and by absorbing the 
discharge prevent its staining the linen. They are 
also very useful in retaining poultices to the head of 
the penis, or dressings to chancres, &c., as they are 
not easily deranged by the erections. The band in these 
cases passes round the hips, as it does round the wrist 
when applied to the finger. 

THE LACED OR BUCKLED BANDAGES, 

Are so named from the manner in which they are 
confined to the part. As they are usually obtained 
from the glovers, or bandage makers, I shall only 
refer to them in passing, as their application is very 
simple, and being somewhat ancient, their use is gene- 
rally understood. 

THE LACED BANDAGE FOR THE KNEE, 

Is made of any elastic substance, such as buckskin or 
kid, lined with Caoutchouc, &c., 
and laces at the side, as seen in Fig. F^sr- 9i- 

91. It is sometimes employed "^ 

where constant compression is re- 
quired, as after dislocations of the 
patella ; in chronic enlargements of 
the joints, &c. When wanted they 
should be made to order, as their 
utility depends on the accuracy with 
which they fit. In Philadelphia, 
they may be found at No. 43 South 
8th, or No. 32 South 6th street, or of the cutlers, or 
druggists, generally. 




120 



SUSPENSORIES, SHEATHS, ETC. 



Fig. 92. 



THE LACED STOCKING, 

Is employed in the treatment of varicose veins ; 
for the support of tender and extensive cica- 
trices of the leg ; and in old ulcers, &c., being occa- 
sionally preferable in these 
cases to the ordinary ban- 
dage, as it presses uni- 
formly throughout its whole 
extent ; may be readily ap- 
plied by the patient, and worn 
under a boot. Where this 
bandage cannot be obtained 
ready made, slit a common 
strong cotton stocking down 
the side, and hem in on each 
edge a ver^y thin slip of whale- 
bone. Then work a few eye- 
let-holes along the edges be- 
hind the bones, as in the 
corsets of the female, and 
fasten it up by lacings. 




THE LACED GAITER FOR THE FOOT, 



Fig. 93. 




Is constructed like the knee- 
cap, of buckskin, cloth, kid, 
and laces along the outside 
of the foot and ankle, as in 
that daily worn over a shoe. It 
serves admirably for supporting 
the parts after sprains, or 
weakness of the lower portion of 
the leg and foot; in the cure 
of old ulcers on the malleoli, 
and of oedematous swellings 
of the ankle generally. 



PART II 



CHAPTER I. 



OF THE HANDKERCHIEF SYSTEM OF M. MAYOR, 
OR THE SYSTEM OF PROVISIONAL DRESSINGS. 

Before taking up the consideration of particular 
fractures and dislocations, it will perhaps not be un- 
interesting to examine the new system of bandaging 
of Mr. Mayor, or the system in which he proposes and 
practices the employment of such simple means as 
are always at hand, or which may often supplant, 
with advantage, the means already mentioned, and 
supply their place whenever they cannot be obtained. 
" The more readily we can procure such means, the 
greater also their simplicity and uniformity, the less 
embarrassing will it be for the surgeon to fulfil his 
duties, the less perilous will be the progress of the 
treatment, and the less doubtful the chances of its 
termination. These observations apply w^ith particu- 
lar force to the circumstances in which surgeons are 
often placed, especially when practising among the 
poorer classes, in the country, in thinly-peopled dis- 
tricts, or in the army or navy, where hospital stores 
havefailed or are rapidly diminishing." In doing this, 
M. Mayor has made such a sim])lification of surgical 
apparatus, that under any, even the most disadvan- 
tageous circumstances, relief may be afforded, and a 
plan of cure employed as safe and as commodious 
as that generally recommended. 

The principle he has laid down is, to use his own 



122 HANDKERCHIEF SYSTEM 

words : — "To reduce as much as possible all kinds 
of apparatus to their most simple principles, by making 
them dependent upon particular and uniform ideas : 
in order that the parts of such apparatus, or the ma- 
terial objects of any dressing, may be so common, 
and of such a nature, as to be met with under every 
or nearly every circumstance, no less at the dispo- 
sition always of the surgeon, than of other persons ; 
and that, in the absence of a scientific man, they may 
be applied with facility by the first comer, after very 
little instruction. In other words, to find out a means, 
simple, easy of application, ever at hand, or at least 
always to be obtained, which may replace lint, com- 
presses, bandages, and ligatures, such as surgery 
ordinarily requires for the various species of dress- 
ing."* 

This principle cannot be too highly appreciated, 
nor too generally adopted, and to M. Mayor is due 
the credit of prosecuting it to perfection ; although for 
many years exposed to the sneers and ridicule of his 
professional brethren. His plans of treatment are 
now meeting everywhere with the respect they merit, 
and daily becoming better known, not only in Europe, 
but also in the United States. 

It would be impossible in our present limits, to 
treat at length of all this surgeon's objections to the 
common modes of dressing and bandaging, or give 
the fullest details of his method of treatment. We 
will, however, refer to the most interesting of his 
matter, believing that many valuable hints may be 
derived from it, even by those who would not feel 
inclined to abandon, altogether, the older and still 
more scientific methods employed in the treatment of 
surgical accidents. 

It has not been M. Mayor's object, as he expressly 

* JSToiiveau Systeme de Deligation Chirurgicale, Paris, 1 838, 
p. 16, Introduction. Troiseme edition, avec un Atlas. 



OF M. MAYOR. 123 

says, " to banish wholly from the domain of surgery, 
charpie, lint, bands, &c., notwithstanding that such 
would be rigorously possible ; but he has been so 
often struck with their abuse and their almost exclu- 
sive employment, that he could not forbear exposing 
their numerous inconveniences in practice, and en- 
deavouring to establish his own motives for what he 
admits to be their quasi-exclusion.'^^ 

The principal objection which he makes to the 
common bandage, "is in relation to its frequent ab- 
sence in time of need, and the occasional impossi- 
bility of procuring any ; then the serious inconveni- 
ences with which their application may be attended 
when performed by unskilful hands ; for even under 
the best opportunities the habit of applying them re- 
quires time, and is susceptible of being speedily lost. 
Bandages, also, are liable to become relaxed, easily 
deranged, and corded, thus inflicting injury in a va- 
riety of ways, and rendering their frequent re-appli- 
cation a matter of essential necessity ; their diversity 
of length and breadth is also more or less perplexing 
to some ; to roll them well is troublesome; and when 
to these Avell-founded objections to their exclusive 
employment, is added the difficulty of having them 
always clean and neat, as well, also, as the litde care 
that patients take of them when they are not abso- 
lutely wanted, it must be evident that some other 
means are requisite, to rid the surgeon of so many 
causes of vexation and embarrassment ; and that, 
when such are found, they must be hailed by the 
profession with something like satisfaction. 

" Now, all the inconveniences here spoken of may 
be avoided, and all the good desired, obtained, from 
a bandage either of the original form of a cravat or 
pocket-handkerchief, or of the principal modifications 
of this, adapted to the nature of the case." M. Mayor 
makes four modifications of a handkerchief or cravat- 
shaped piece of linen, subservient to all the objects 



124 HANDKERCHIEF SYSTEM 

of a bandage ; such as, the Oblongs the Cravat-shaped y 
the Triangular, and Cordiform ; the latter being only 
employed as a substitute for a cord, or strong tie, in 
certain cases. 

None of the objections made to the ordinary band- 
age can, M. Mayor thinks, be applied to this. " It is 
found everywhere, and under every circumstance ; 
is easily adapted to its purpose ; is not liable to be- 
come relaxed or otherwise deranged, and cannot be- 
come corded ; it is easy to fasten ; may be changed 
and reapplied with the utmost promptitude, as a sin- 
gle circumvolution of it is often equal to a multitude 
of turns of the common band ; is also more econo- 
mical, as it may always be washed, and made ready 
to apply to other than to surgical purposes ; the thick- 
ness and breadth can be varied at will : in short, it 
is so much the more perfect as it forms one whole, 
while each turn of a common band, being considered 
as a piece apart, the derangement of one necessarily 
entails the derangement of all the rest." 

It is not, however, pretended by him, that this new 
description of bandages can supply, completely, the 
place of common surgical bands ; for, as he justly 
observes, ^' there are cases which require a methodic 
compression of a certain energy, more particularly 
some affections of the breasts and of the extremities ; 
but these are comparatively rare ; and exception be- 
ing made of such, the new description, as being the 
most valuable, should be employed in common, while 
bands should form but the exception to this general 
rule." 

In the application of the handkerchief, or triangular 
piece of linen, to cases in which it may be adapted, 
M. Mayor commences at the head, and then, as in our 
present arrangement, proceeds regularly to the trunk 
and extremities. In pursuing this course, he desig- 
nates his handkerchief bandages by certain names, 
which may at first sight appear to be unnecessary and 



OF M. MAYOR. 



125 



pedantic. But when it is recollected that the arrange- 
ment of the name shows the course to be pursued in 
the application of the handkerchief, it will be seen 
that it is of considerable importance, and that it aids 
us materially in their application ; thus, in the Fronto- 
Occipital Triangle, we have the shape of the handker- 
chief, and the statement of the fact that, it is to be 
first applied to the forehead and then to pass to the 
occiput; so inihe Fronto- Cervico-LabialiSy or the Occi- 
pito-Sternal, we know that it should cover, first the 
forehead, then the neck, then the lip ; whilst the 
other starts from the occiput, and ends at the sternum. 

THE HANDKERCHIEF, OR SQUARE LINEN, 

May, according to M. Mayor, replace all the bandages 
that we have before 

treated of, and in -^«^- 94. 

its dimensions, as 
well as in the tissue 
composing it, must 
be regulated by the 
size of the part to 
which it is to be 
applied, or the cir- 
cumstances of the 
moment. It is, 
therefore, a mat- 
ter of indifference, 
whether it be of silk, cotton, or linen ; and if too 
short to go round a part at the time of its application, 
may be easily lengthened by attaching to its extremi- 
ties, two pieces of tape or ribbon. 

From this original piece we may form all the others, 
by folding it according to the dotted lines of Fig. 
94 ; thus, if the four angles are folded into the cen- 
tre, g-, we shall have a smaller square, which may be 
again reduced by repeating the process. In this shape 
it answers very well for the application of warm, fo- 




126 



HANDKERCHIEF SYSTEM 



meriting poultices, which may be thus easily retained 
between the two layers of the handkerchief. If the 
square handkerchief is folded from angle to angle, 
we shall have the 

TRIANGLE. 

This triangle varies in size according to the part 
to be covered in by it ; though the largest of those 
employed at Lausane was about a yard in length, 
and a half yard from its summit to the centre of its 
base. When we wish to have a smaller triangle, 
divide this according to the line c d, or cut off por- 
tions on each side. Thus formed, the parts of the 
triangle, are the Base, a 6 ; the Angles or Extremities, 
or points of these same letters ; and the Summit, c. In 

Fig. 95. 




order to apply it, hold it smoothly by the base, 
placing the thumbs above or on its upper surface, 
and the fingers, widely extended on its under surface ; 
then apply the base first, and carry the extremities 
around the part so as to cover in the summit, making 
folds or plaits in any portion of it that may project. 

The Oblong Square, as in Fig. 94, does not require 
much explanation, as it is readily seen to be formed 
of the common square, doubled once on itself. 

'''^ The Cravat, Fig. 95, is so well known, as also 
to require no explanation, the shape being that 
which we daily employ in arranging the covering to- 



OF M. MAYOR. 127 

our necks. Like the triangle, the body, or base, a, 
is the part first applied, and this is retained in its po- 
sition by attaching its ends, b c, to other parts of the 
body. 

The Cord, is made by twisting the cravat on itself, 
and is of great utility in compressing vessels, espe- 
cially as a substitute for the tourniquet. 



H 



128 



OF THE HANDKERCHIEFS 



CHAPTER II. 



OF THE HANDKERCHIEFS AS APPLIED TO THE 
HEAD. 

The first application of the handkerchief is to cover 
in the whole head, and is called 

THE SQUARE CAP OF THE HEAD. 

Form the handkerchief into an oblong square, and 

let the edge of the 
Fi£^.96. side to go next the 

head, be two inches 
shorter than the other. 
Draw the ends of the 
long side down the 
side of the face, and 
tie them under the 
chin ; then draw the 
inner ends, or those 
of the short side for- 
wards, to free them 
from the former, and 
folding this part back- 
wards, tie the ends on 
the occiput. 

Use. — To cover in the head, ears, and jaw. 




IN THE FRONTO-OCCIPITAL TRIANGLE, 

The base is placed before the forehead, higher or 
lower, according to circumstances ; and the lateral 
angles or tails are crossed at the occiput, from whence 
they are to be brought forward as far as the temporal 



AS APPLIED TO THE HEAD. 



129 



regions, or on to the forehead, where they are to be 
fixed by means of pins. Fig. 97. 

Fig. 97. 




The summit is then conducted and fixed at the 
occipital region, by being made to pass under the 
posterior portion, from whence it is reflected upwards 
and pinned, as in Fig. 98. 

Fig, 98. 




Use, — To retain dressings to the head. 

FOR THE OCCIPITO-FRONTAL TRIANGLE, 

Place the base at the occiput ; cross the tails upon 
9 



130 



OF THE HANDKERCHIEFS 



the forehead, and pass the summit underneath the 
frontal portion so as to reflect it upwards. 

Use, — Same as the former, but more useful when 
a little pressure may be required on the forehead. 
This is made by the crossing of the angles, or by 
knotting them. 

IN THE BI-TEMPORAL TRIANGLE, 

The base is placed upon one of the temples, ^nd the 
summit turned over towards the opposite ear and con- 
fined by the angles carried around the head. 
Use. — To retain dressings to the temples. 

THE SIMPLE OCCULO-OCCIPITAL TRIANGLE, 

Requires that the base should be stretched obliquely 
from the superior part of the temporal region of the 
sound side, over one eye, to the sub-mastoid region 
of the diseased side ; the summit being carried diago- 
nally backwards to the posterior portion, where it 
crosses at the side of the neck corresponding with the 
sound eye. 

Use. — To cover in one eye. 

IN THE FRONTO-OCCIPITO-LABIALIS CRAVAT, 

Place the body against the forehead, cross the tails 

on the nape of the neck, 



Fiff. 99. 




and bring them forwards 
to either lip, where one 
may be passed through 
a slit perforated near the 
extremity of the other. 
These extremities are 
then pulled in contrary 
directions, over the com- 
presses on each side of the 
wound, and secured by a 
couple of small pins or a 
few stitches, underthe ears. 



AS APPLIED TO THE HEAD. 



131 



If a triangle is used, the summit should be carried 
to the occiput, passed under the first inter-crossing, 
reflected upwards and pinned. Fig. 99. 

Use. — To sustain the union in wounds of the 
lip, or after the hare-lip operation ; and to confine the 
dressings, or unite wounds in the absence of other 
means. 



■ 



IN THE FACIAL TRIANGLE, OR MASK, 

Place the base under 

the chin, the summit Fis^. lOO. 

on the forehead, and 

carry the angles over 

the ears to the vertex, 

where they may be 

crossed and brought on 

the forehead, in order 

to confine the summit. 

Holes or slits are then to 

be made for the eyes, 

nose, and mouth. 

Use. — To retain dressings to the face. 




IN THE VERTICO-MENTAL CRAVAT, 



Fiff. 101. 



The body of a broad 
cravat is placed on the 
vertex, and the ends 
carried under the chin, 
and fastened to the 
sides of the first turn, 
near the ears. 

Use. — To retain 
dressiftgs under the 
chin, or to the base of 
the jaw. 



THE OCCIPITO-AURICULAR TRIANGLE, 

Is made by the base being placed obliquely in front of 




132 



OF THE HANDKERCHIEFS 



the injured ear,and the summitcarriedroundtowardsthe 

same ear. One angle then 
Fi£: 102. going under the jaw of the 

side affected, comes up in 
front of the opposite ear, 
where it makes a knot which 
ties under the ear, or a turn 
around the other angle, so 
that the two may run round 
the head, the one in front, 
the other behind, to tie on 
its side, or on the jaw. 

Use. — To retain dress- 
ings to one ear, or to the 
angle of the jaw, without 
interfering with the oppo- 
site ear. Fig. 102. 

THE OCCIPITO- STERNAL HANDKERCHIEF, 

Requires two handkerchiefs, one in cravat, the 
other in triangle. Place the base of the triangle on 

Fi^. 103. 





the occiput, with the summit anteriorly, and bring the 



AS APPLIED TO THE HEAD. 



133 



tails down along the sides of the head and face, so as 
to fasten them to the front of a sterno-dorsal or dorso- 
thoracic cravat. Fig. 103. 

Use. — To unite wounds of the throat, and bring 
the head to the chest. 



THE FRONTO-DORSAL, 

Is the reverse of the above. The base of the tri- 
angle is upon the forehead ; the summit carried 
posteriorly ; and the tails are turned downwards and 
backwards, to be fastened to the back of a dorso- 
thoracic cravat. Fig. 104. 

Fig. 104. 




Use. — Reverse of the former, or to unite wounds 
of the back of the neck, &c. 



IN THE PARIETO-AXILLARIS, 

Place the base of the triangular handkerchief on 
one side of the head, with the summit carried to the 



134 HANDKERCHIEFS AS APPLIED TO THE HEAD. 

opposite side, and tie the ends to an axillo-acromial 
cravat, as in Fig. 105. 

Fig. 105. 




Use. — To bring the head to one side, as in wry- 
neck, spasm of sterno-cleido muscle, &c. 



HANDKERCHIEFS FOR THE TRUNK. 



135 



CHAPTER III. 

OF THE HANDKERCHIEFS AS APPLIED TO THE 
TRUNK. 

The first of these is very simple, and constitutes 

THE CERVICAL CRAVAT (OF DAILY USE). 

It has the centre before the larynx, the side of the 
neck, or against the cervical vertebrae, according to 
circumstances ; constituting an anterior^ lateral, or 
posterior cervical cravat. 

Use. — As a retaining bandage for dressings ap- 
plied to the neck. 

IN THE SIMPLE BIS-AXILLARY CRAVAT, 



Place the centre in 
the axilla of the af- 
fected side ; cross 
the tails over the 
corresponding shoul- 
der, and then carry 
them one before, the 
otherround and behind 
the chest, to the axilla 
of the opposite side, 
where they are to be 
secured. Fig. 106. 

Use. — To retain 
dressings to the axilla. 



Fi^. 106. 




IN THE COMPOUND BIS-AXILLARY CRAVAT, 

Place the centre of a cravat on the axilla of the sound 
side ; carry the tails obliquely upwards to the base of 
the neck at the opposite side, and fasten their extre- 
mities ; next, apply the centre of a second, and smaller 



136 HANDKERCHIEFS AS APPLIED 

Fig. 107. 




cravat, in the axilla of the affected side, and attach its 
tails to the corresponding portion of the first. Fig. 107. 
Use. — Same as former, but to both axillse. 

IN THE SIMPLE BIS-AXILLO-SCAPULARY CRAVAT, OR 
POSTERIOR 8 OF THE SHOULDER, 

Fig. 108. Place the centre be- 

tween the scapula, carry 
one of the tails round 
the corresponding shoul- 
der and axilla, and fasten 
the extremity by strong 
stitches to the body of 
the cravat ; in the next 
place, conduct the other 
tail under the corre- 
sponding axilla, and 
over the shoulder, to- 
ward the extremity of 
the first, upon which it 
should be similarly se- 
cured, as in Fig. 108. 
TJse. — Same as the preceding. 




TO THE TRUNK. 



137 



IN THE COMPOUND BIS-AXILLO-SCAPULARY CRAVAT, 

Knot together the two extremities of a cravat about 
one of the shoulders, so as to make of it a loose ring : 
next, take a second cravat ; apply the centre of this 
against the anterior face of the other shoulder, and 
conducting the tails one over the shoulder, and the 

Fi^. 109. 




other beneath the axilla, let the first embrace the cor- 
responding portion of the ring, in order that its ex- 
tremity may be united with that of the second tail, 
which should be made previously to pass about the 
first, in the manner represented in Figure 109. 

Use. — Same as the two preceding, but preferable 
to either, on account of the much greater power it 
may be made to exert. 

FOR THE DORSO-BIS-AXILLARIS, 

Place one handkerchief in a cravat round the chest 
under each axilla, and the other in a triangle on the back, 



138 



HANDKERCHIEFS AS APPLIED 



^^^' !!<>• with its base upwards. 

Fix the summit of the 
triangle to the circular 
cravat,and carry the an- 
gles over each shoul- 
der and axilla to fasten 
to the circular hand- 
kerchiefbehind, and on 
the sides. Fig. 110. 

Use. — To retain 
dressingsto these parts. 
If the summit is fixed 
to the circular cravat 
in front, and the angles 
brought over each 
shoulder to fasten be- 
hind, it will retain dressings to the front of the chest, 
and form a Cervico- Thoracic Handkerchief. 

IN THE TRIANGULAR CAP OF THE BREAST, 

Place the base of a triangle obliquely across the chest 
Fig. 111. 





TO THE TRUNK. 



139 



under one breast, with the summit over the correspond- 
ing shoulder ; one angle over the opposite shoulder, 
and the other under the corresponding axilla, to tie on 
the back and confine the summit. 

Use. — To retain a dressing to, or support the 
breast. 

IN THE SUB-FEMORAL HANDKERCHIEF, 

One handkerchief in a cravat, goes circularly around 

Fi^. 112. 




the pelvis. The base of another, which is in a tri- 



140 



HANDKERCHIEFS AS APPLIED 



angle, is applied obliquely on the thigh, the angles 
passing circularly around its upper part, and the 
summit obliquely up between the nates, to be fixed 
to the circular band, as at A, Fig. 112. 

Use. — As a means of covering in the pelvic 
portion of the body, and the only one that does it 
with neatness and accuracy. 

THE INTER-FEMORAL HANDKERCHIEF, 

Requires the base on the back of the body ; the an- 
gles brought round the pelvis ; and the summit to be 
carried over the perineum, to fasten in to the angles 
in front, as in the diapers of children. 



Fig. 113. 




IN THE SINGLE SPICA, 

Place the body of a cravat in 
the line of the groin and 
carry one extremity around 
the pelvis, the other around 
and below the thigh, to meet 
it on the groin. If not long 
enough, attach tapes to its 
extremities. 

Use. — To retain a dressing 
to one groin. 

FOR THE DOUBLE SPICA, 



Fig. 114. 




Fold two handkerchiefs in 
cravats, and tie an extre- 
mity of each together. 
Place the knot a little on 
one side of the spine, and 
carry the other extremity 
of each, round over either 
innominatum, in the line of 
the groin, between the 
thighs, and round their 



TO THE TRUNK. 



141 



outside, to come up and fasten to the bodies of the 
cravats. 

Use — To retain dressings to both groins. 

TO MAKE THE SUSPENSORY OR SCROTO-LUMBAR 
TRIANGLE, 

Form a lombo-abdominal cravat for a belt, and apply 
the base of a triangle to the under and back part of 
the scrotum ; carry the 
tails up alongside of this •^^^' ^^^' 

to the forepart of the belt ; 
pass them about this, 
from before backward, as 
represented in Fig. 115, 
and tie the extremi- 
ties, so as to bring the 
knot in front, and prevent 
its chafing. Next carry 
the summit upwards, pass 
it under the transverse 
portion of the tails and 
under the belt, reflecting it over the forepart of the 
apparatus, so as to secure it with a pin. 




142 



OF THE HANDKERCHIEFS 



CHAPTER IV. 

OF THE HANDKERCHIEFS OF THE UPPER EX- 
TREMITIES. 



The handkerchiefs of the Upper Extremities are 
an excellent class of bandages, and may frequently 
supplant the ordinary roller with advantage. 

THE CERVICO- BRACHIAL SLING, 

Is made by placing one handkerchief in a cravat around 
the neck, and knotting its ends over the sternum. 

Place the other in 
■^^^' ^^°' a triangle under 

the forearm, so that 
its base may be 
next the wrist; then 
tie its angles to the 
cravat, and carry 
the summit around 
the elbow to fasten 
it to the body of the 
triangle in front. 

Use. — To sup- 
port the forearm. 
This method of 
forming a Sling is better than the common plan, as 
the knots do not cut the back of the neck, owing to 
the position of the cravat, whilst the summit of the 
triangle, being fixed at the elbow, keeps the arm 
more closely to the side of the body. 

THE ANTE-BRACHIAL TROUGH, 

May be either constructed of leather or pasteboard, 
which latter may be covered by some appropriate 




OF THE UPPER EXTREMITY. 



143 



material with the view of preserving its form, or 
even giving it a sort of embellishment. It may be 
either straight, that is to say, open at the level of the 
elbow, or, as represented in Fig. 117, terminat- 
ing there in a cul-de-sac. A long riband or cord is 
required to serve for its suspension, and constitute 
two collateral bows to which the author applies the 
term arc-loops ; — lastly, a cravat, so arranged as 
to constitute a Cervical 
Cravat. Four holes be- 
ing previously, bored 
through the trough at con- 
venient distances apart, 
near its borders, the 
cord is run through them, 
in order to form the 
loops, which in their pas- 
sage, should be made 
either to glide through 
the Cervical Cravat, as 
represented in Fig. 117, 
or what is better, through 
a ring, which serves to 
connect them, and allows 
loops; from 
convenience 




of a free play of the 
this the patient will derive no small 
When the apparatus is thus prepared, 
nothing remains to be done but to introduce therein 
the patient's forearm, which has been, if fractured, 
previously furnished with its bandage. 

Use. — This apparatus may be worn enclosed in 
the patient's ordinary dress, so as not to give the 
appearance of the arm being subjected to confine- 
ment. But if, it be required to preserve the elbow 
fixed against the trunk, a riband must be made to 
pass through a couple of holes perforated in the in- 
ternal portion of the trough, or that which corre- 
sponds to the body, and embrace the trunk, as a 
belt or body-bandage. If it be necessary to give 



144 



OF THE HANDKERCHIEFS 



support to the hand or wrist, a thin, flat piece of wood 
may be laid at the bottom of the trough, and its pro- 
jection beyond the end of the latter regulated by cir- 
cumstances. 

IN THE TRIANGULAR CAP OF THE SHOULDER, 



Fig. 118. 




Place the base of the triangle at the 
insertion of the deltoid muscle, or 
elbow, the summit over the acro- 
mion, and carry the angles round 
the arm, and tie them on it as in 
Figure 118. 

Use. — To retain dressings to the 
round part of the shoulder or middle 
of the arm, which it does very per- 
fectly. 



IN THE TRIANGULAR CAP FOR THE HUMERUS AND 
ALL OTHER AMPUTATIONS, 

The base of a triangle is to be conveniently placed 
under the limb, at a convenient distance from the 
extremity of the stump ; the tails are then to be 
brought forward and overlapped, and the summit 
carried over the stump and fastened to the circular 
portion, or the angles. In this last part of the pro- 
cess, care should be taken that the handkerchief, or 
linen embraces, very accurately, the extremity of the 
stump, as shown at page 27. 

Or, instead of commencing with the lateral angles, 
the summit may be first carried upwards in the man- 
ner described, and then the tails, in encircling the 
limb, may be made to include its extremity. 

Use. — Whether employed in amputations of the 
upper or lower limbs, of the fingers or toes, or even 
of the penis, nothing can be more simple or more 
effectual than this bandage. In general, no further 



OF THE UPPER EXTREMITY. 



145 



precaution is necessary, than to insist upon the patient 
remaining quiet ; for if the apparatus be carefully- 
applied, there will be hardly a possibility of any de- 
rangement. But should it be absolutely necessary 
to have recourse to some expedient to prevent the 
apparatus from becoming detached, a cravat belt may 
be applied about the neck, or pelvis, the lower part 
of the arm, or thigh, the wrist, or ankle, according 
to the seat of the operation, and the limb may then 
be fastened to this by bands or tapes. 

IN THE CARPO.OLECRANIEN, 

Fold two handkerchiefs into cravats, and apply one 
circularly around the arm above the elbow. Then 
tie one extremity of the other around the articulation 
of the carpal and metacarpal bones, so that the knot 
may come on the back of the hand, and attach the 
other extremity to the circular cravat, as in the arm 
of Fig. 112. (B.) 

Use. — To keep the forearm extended. When a 
splint is passed under each handkerchief on the front 
of the arm, it answers very well in the latter stages 
of fracture of the olecranon. 



IN THE FLEXOR OF THE WRIST, 

Place a cravat circularly round the Fig- 119. 

arm above the elbow, and a trian- 
gle around the hand so that the 
summit may be folded over it, and 
fastened by one angle around the 
wrist. Flex the hand and fore- 
arm, and attach the other angle 
to the cravat on the front of the 
arm, as in Fig. 119. 



10 




146 



OF THE HANDKERCHIEFS, ETC. 



FOR THE CARPO-DORSAL, OR PALMAR TRIANGLE, 

Place the base of a triangle on the dorsal or palmar 
surface of the wrist, and carry the angles round this 
and the summit over the fingers, which should be 
flexed, as in Fig. 120, if a dorsal handkerchief is 

wished. If not, slit 
Fig, 120. holes in the handker- 

chief, as in the perfor- 
ated T of the hands, 
and passing the fingers 
through them, attach 
the summits to the 
angles. 

Use. — To retain 
dressings to the back or front of the hand, or between 
the fingers. 




OF THE HANDKERCHIEFS, ETC, 



147 



CHAPTER V. 



OB^ THE HANDKERCHIEF OF THE LOWER EX- 
TREMITIES. 

These handkerchiefs supply a covering for parts 
that often embarrasses the practitioner to retain dres- 
sings on, by any other means. The first is : — 



THE METATARSO-MALLEOLAR CRAVAT. 

Place the body of the cravat obliquely across the in- 
step, and carry one extre- 
mity round above the mal- 
leoli, the other round the 
sole of the foot and instep, 
to join it on the front of the 
ankle. 

Use. — To retain d ressings 
to this part, as after tying 
the anterior tibial artery ; 
but where pressure is requir- 
ed, the spica of the instep 
should be substituted. 




TO MAKE THE TRIANGULAR CAP OF THE HEEL, 

Apply the base, to the sole of the foot, directly under 
the instep ; summit over one malleolis; angles crossed 
on instep, and then carried around the malleoli to 
confine the summit, as in the foot of Fig. 122. (A.) 

Use. — To retain dressings to the heel. This is an 
excellent bandage in the treatment of the excoriations 
often consequent on the use of the extending band in 
the treatment of fractures of the thigh. 



148 



OF THE HANDKERCHIEFS OF THE 



THE TARSO-PELVIEN CRAVAT, 

Requires one circular cravat around the pelvis, and the 
body of a second on the top of the foot, with one end 
tied under the sole, the other fastened to the pelvic 
band, as at B. 




Use. — To support the limb and keep the foot 
extended, as in ruptured tendo-Achillis. 



THE COMPOUND METATARSO-ROTULAR CRAVAT, 

Is composed of four cravats ; — a hollow paste-board 
or split deal splint, and some soft compresses. Then 
the patient's limb should be placed in the most com- 



LOWER EXTREMITIES. 149 

plete extension, and the heel kept elevated above the 
level of the tuber ischi by means of a pillow. The 
centre of the first cravat is to be applied against the 
anterior part of the thigh, immediately above the pa- 
tella, and its extremities carried backward, crossed, and 
returned to the anterior part of the leg immediately 
below that bone ; by drawing on these, the two broken 
surfaces will be placed in tolerable apposition. The 
centre of the second cravat should then be applied 
against the sole of the foot ; one extremity loosely 
knotted upon the metatarsus, and the other subse- 

Fig. 123. 




quently carried upwards on one side of the knee to 
the supra-rotular portion of the first cravat, to which 
it is to be attached, as seen in Fig. 123. The 
sole of the foot here serves for a point of support ; 
and this second cravat, aided by the respective posi- 
tions of the leg, of the thigh, and of the pelvis, tends 
to counterbalance the action of the extensors of the 
leg ; but, to obviate still more any possibility of flex- 
ion of the latter upon the thigh, which these cravats 
would not in all instances be enabled of themselves to 
counteract, recourse is had to a hollow splint, which 
is well lined with soft compresses, and applied against 
the posterior surface of the limb. This is fastened in 
the simplest manner, by the two remaining cravats. 

Use. — In fractured patella ; incised wounds of the 
knee, &c. 



150 



OF THE HANDKERCHIEFS OF THE 



THE TARSO-PATELLA CRAVAT, 




Requires one handkerchief in 
a cravat around the knee in a 
figure of 8, so asto embrace 
the patella; the middle of an- 
other being under the instep, 
and one end tied on its out- 
side, the other passed under 
the cravat at the knee, as in 
Figure 124. 



Use. 
patella. 



In fracture of the 



IN THE MALLEOLAR PHALANGIAI, TRIANGLE, OR CAP 
OF THE FOOT. 



P/^. 125. 




Place the base of the triangle un- 
der the instep ; summit over the 
toes ; angles around malleoli to en- 
close the whole foot. 

Use. — To retain dressings to the 
foot. 



IN THE TIBIO-CERVICAL CRAVAT, OR SLING, 

Apply the body of a cravat to the shoulder opposed 
to the side affected, and bring down the tails obliquely, 
to just above the crest of the ilium of the side cor- 
responding to the injury, so as to give it, when knot- 
ted, the appearance of a band. Then, flexing the 
leg to a right angle, apply a triangle on its anterior 
face, the base corresponding to the ankle, and the 
summit to the knee ; then carrying the tails, one 
along the inside, and the other along the outside of 



LOWER EXTREMITIES. 



151 



the thigh, and attach their extremities, securely, to the 
cervical cravat, near the pelvis. 

Fig. 126, 




Use. — To support the limb after the treatment of 
fractures of the leg, or in sprains, where the patient 
is desirous of walking about. 



152 



OF THE HANDKERCHIEFS, ETC. 



Fig. 127. 




IN THE TIBIAL CRAVAT, 

Place the body of a broad cravat 
obliquely across the back of the 
leg, and carry one extremity round 
the leg below the knee, the other 
above the ankle ; to meet and tie, 
or pin, on the front of the calf, or 
spine of the tibia. 

Use. — To confine Sinapisms, 
Blisters, &c., to the calf. The figure 
of 8 turns of this handkerchief, pre- 
vent its becoming deranged by the 
movements of the patient.* 



BARTON'S HANDKERCHIEF. 

A very excellent method of making an extending 
band for the treatment of fracture of the thigh, has 
been proposed by Dr. J. Rhea Barton, of Philada. 
Dr. Barton was led to this application of the handker- 
chief by seeing how well the pressure of the boot on 
the heel and instep was borne, and how frequently 
excoriation and troublesome ulceration of the heel 
followed the use of the ordinary band or gaiter, which 
pressed directly on the sharp edge of the tendo- 
Achillis. With these views, he folded a handker- 
chief into a narrow cravat, and placed the body of it, 
directly on the extremity of the os calcis, below the 
tendo-Achillis, so that two-thirds of the cravat came 
round under the outer malleolus, and the other third 
remained on the inside. The inside portion remain- 
ing parallel with the sole of the foot, the outside 
piece is carried over the instep and passed round it, 



* Mayor's Nouveau System. 



MAYOR'S SYSTEM. 



153 



so as to form a sort of knot, and 
also passed under the sole of the 
foot, to be turned around the first 
turn, and form another knot at 
the metatarsal articulation, when 
both ends are carried off perpen- 
dicularly from the foot and fast- 
ened to the splint, the pressure 
coming directly on the instep and 
point of the heel, as seen in Fig. 
128. 

When ulceration on the front 
of the ankle-joint, or on the heel, 
has been produced by the use of 
the ordinary means, this will be 
found to avoid the sore points, 
and yet keep up a permanent extension. 



Fig. 128. 




We have now given an account of the manner 
in which the Handkerchief is frequently employed 
as a substitute for the ordinary roller ; and therefore 
pass in order to preserve the continuity of ideas, to 
the Hyponarthecia of Mayor, or peculiar means of 
treating fractures, as described in '' Cutler on Band- 
aging, &c." including a detailed account of his 
Clinical Frame ; our wish being to offer as great a 
variety as possible of the means of treating surgical 
injuries, in the belief that each one will take from them 
what is most desirable. 

" In 1812, Mr. Sauter published, at Constance, a 
work entitled, ^ Instructions for treating safely, com- 
modiously, and without splints, fractures of the ex- 
tremities, particularly the complicated ones, and those 
of the neck of the femur, by a method new, easy, 
simple, and economical.' This work, published in 
German, was somewhat voluminous ; and in order to 
render the subject matter more intelligible, M. Mayor 
translated freely whatever appeared to be the most 



154 MAYOR'S SYSTEM. 

prominent features of this novel invention, and pub- 
lished them in the work from which his system has been 
taken. Perceiving fully the advantages that might be 
derivable from the new system, he adopted it exclu- 
sively, and having submitted it to the test of fourteen 
years' experience and observation both in the Hospital 
of Lausanne and in his private practice in the Canton, 
which was very extensive, he published, under the 
title of * Memoire sur I'Hyponarthecia,' the various 
modifications he had deemed necessary, to give to 
this mode of treatment its greatest efficiency. His 
reasons for adopting the term Hyponarthecie (vro^ 
under ; v*/)S«|-, splint), were based upon the fact that 
the planchette, or Schebmachine, or support of M. 
Sauter, upon which the limb reposes, was in itself a 
splint. This term is expressive of the system, and 
has therefore been Anglicised. 

'* To set out, the problem proposed by M. Sauter, 
a problem so difficult that it almost seems a paradox, 
but which he has ably resolved, was ^ to treat a broken 
limb, with even the most seiious complications, by posi- 
tion only, and without the use of splints ; and to permit 
the limb, at the same time, to execute, without pain or 
inconvenience, every movement parallel to the horizon.'^ 

" This apparatus consists in a board properly 
cushioned, upon which the injured limb should be 
placed and fixed in the position which it is necessary 
to give it. The board thus charged, is attached to the 
ceiling or the top of the bed by means of cords, which 
are run through holes pierced in its borders and sus- 
pended above the bed, so as to render it freely move- 
able. For the purpose of fastening the limb, two or 
three cravat-shaped ligatures are employed, which, in 
case of need, and with a certain modification of this 
apparatus, namely, a foot-board or ladder, will equally 
serve for the execution of traction or extension. But 
these ligatures, besides fixing the limb, exert a spe- 
cific action upon the fragments themselves ; for, acting 



MAYOR'S SYSTEM. 155 

in contrary directions, they keep the fractured ends 
of the bone themselves, as well in juxta-position, as 
in the most complete immobility : so that this simple 
contrivance not only effectually produces the neces- 
sary traction in the axis itself of the bone, but even 
similar tractions directly transverse to it ; an advan- 
tage by which it is distinguished above all other ap- 
paratus for fractures. This state of immobility is im- 
portantly seconded by the soft cushion, which, by 
moulding itself to the form of the limb, guarantees 
the security of its under part, or that which alone can 
be said to be excluded from the direct action of the 
transverse ligatures. 

" But how, it may be asked, are the involuntary 
muscular efforts of the limb to be controlled ? The 
answer to this is, that they soon terminate even under 
ordinary circumstances, and they do so in this case so 
much the sooner, as they are not stimulated and kept 
up by the weight or offensive pressure of ordinary 
apparatus. 

" As the whole limb rests exposed to view, the in- 
spection of the practitioner will discover at once the 
slightest possible displacement, which he will be en- 
abled to remedy with the utmost facility ; at the same 
time that he may employ every kind of therapeutic 
agent in the event of injury of the soft parts. And the 
patients possessing, even under the most serious com- 
plications of their fractures, the faculty of horizontal 
motion, their beds can be easily made, and all the 
other necessary offices readily performed. 

" Not the least advantage peculiar to this apparatus 
is its ready construction ; it may be made at all places 
and under any circumstances, even by the practitioner 
himself; for if, viewing the materials in detail, some 
of these may not be at hand, such, for instance, as the 
pulley for the cords to run through, affixed to the 
ceiling, or the hinges necessary to a jointed board 
(see cuts), or a gimblet to bore the necessary holes, 



156 MAYOR'S SYSTEM. 

substitutes may be instantly found ; as, a staple for 
the first, a bit of strong leather for the second, and for 
the third, a few nails, by which the cords may be 
effectually fixed to the edges of the board. So also 
with respect to the cushion, how many substitutes 
may be found for this ! In short, whether a surgeon 
be called for, in scenes of the greatest poverty, on 
board ship with the fewest possible resources, or in 
the wildest districts, he need never be embarrassed. 

" On board ship it is especially serviceable, as the 
fracture is not easily deranged by the motions of the 
vessel, owing to the limb being allowed to swing as 
well as the body. 

" The reduction of fractures, by the employment of 
this suspension apparatus, is effected thus. The board 
being furnished with its cushion, which should be 
sufficiently thick to constitute a soft bedding, and 
entirely cover it, and the vertical cord, forming a 
loop, properly suspended from the ceiling ; the se- 
cond cord, destined to form the side loops, or arcs of 
the board, is to be run through the holes perforated 
through the angles of this, passing in its course 
through the first or suspension loop, so as to be in 
readiness to comply with any exigencies, in regard 
to length, when the suspension is about to be effected. 
This done, the limb is made to glide along the cush- 
ioned board ; and then the resistance, or counter- 
extension and traction, is resorted to, together with 
the coaptation of the fragments ; and, by means of 
the traction-bands, the position and coaptation of the 
fragments is fairly established. The ladder or foot- 
board, or extension band, will now keep the foot 
steadily fixed, while the due elevation given to the 
centre of the jointed board, if this be used, will con- 
stitute it an excellent double-inclined plane, possessed 
of all the advantages accorded to that species of ap- 
paratus. Lastly, the arc-loops and suspension loops 
are to be regulated so as to raise the limb to a proper 



MAYOR'S SYSTEM. 157 

height, which will be judged of by the surgeon, in 
consulting at all times, however, the feelings of the 
patient. 

" As this kind of apparatus is in the way of the bed 
coverings, some little tact is requisite to overcome 
this trifling impediment; but nothing need be ob- 
served on the subject here, as the good sense of the 
practitioner will always readily suggest means to 
remedy an inconvenience so truly unimportant. 

" The use of the jointed board is strikingly evident 
in fractures of the femur, whether of its shaft or neck : 
it effects, in its quality of double-inclined plane, that 
which modern surgery only has succeeded in obtain- 
ing ; namely, permanent Extension^ joined to double 
Flexion, and the Fixing of the entire limb : but, be- 
sides this, suspension affords the utmost facility of 
motion in mass, by means of lateral action. It will 
be only necessary to observe this apparatus, as illus- 
trated in the cuts, to be convinced how effectually 
the above important objects are attained, and how 
totally impossible it must be for the fragments of the 
bone to ride in cases of oblique fracture, by reason of 
the powerful aid of the pelvic bandages. 

'" Even in fractures of the upper extremities, the 
hyponarthecic apparatus may be sometimes advan- 
tageously employed ; as, for instance, where the frac- 
ture is one of very serious character, and complicated, 
with injuries of the soft parts, which requires that the 
patient should keep his bed, and which precludes, 
from what cause soever, the application of ordinary 
apparatus, as tending to aggravate his sufferings, and 
augment the difficulties of the case. In short, the 
only circumstances in which the invention of M. 
Sauter is contra-indicated, are those in which infants, 
or maniacs are concerned, for reasons which the least 
consideration will render apparent. 



158 



MAYOR'S SYSTEM, 



THE ANTE-BRACHIAL HYPONARTHECIA, 

Consists in a board of convenient width, a little longer 
than the forearm and hand ; — a cushion ; — a cord 
for arc-loops ; and three cravats. Then, the fracture 
being reduced, the forearm is made to repose on the 
cushioned board, a 6, which is immediately put into 
suspension to the patient's neck by means of the arc- 
loops, e e, ring, f, and Cervical Cravat, g. The 
second cravat, c, is now passed under the wrist and 
crossed upon the back of the hand, the tails being 
then made to embrace the cushioned board, and 
knotted at its anterior border, as represented in the 
wood-cut. That done, the third cravat, d, is made 
to pass round the apparatus at its upper part, so as to 

Fi^-. 129. 




confine the corresponding portion of the forearm, and 
be knotted also at its anterior border. Should it be 
deemed expedient, a fourth cravat may be made use 
of, to serve for a traction-band, which w^ill, of course, 
be knotted at the inner border of the suspension board. 
" The advantages that may be derived from the hy- 
ponarthecic apparatus, may here be judged of; for in 
cases of fracture complicated with laceration, or other 



MAYOR'S SYSTEM. 159 

injuries of the soft parts, even occurring at the upper 
extremities, the wounds remain under the constant 
inspection of the practitioner, and are not subjected 
to the incommodious and even dangerous pressure of 
the common bandage, as must be the case when re- 
course is had to it under such circumstances. The 
patient may even be permitted, by the employment 
of this apparatus, to take exercise, when the injuries 
of the soft parts are not very grave ; but if, on the 
contrary, perfect repose be deemed essentially neces- 
sary, instead of the above apparatus, a board should 
be procured, which, extending from the axilla to be- 
yond the finger's ends, should be well cushioned, and 
maintained in place by means of a Bis-Axillary 
Cravat. The board may then be put into suspen- 
sion, and the above cravat adapted to suit the ob- 
ject in view in the following manner : — The cen- 
tre of the cravat should be applied to the axilla of the 
sound side, its tails carried before and behind the 
chest to the opposite shoulder, crossed thereon, and 
then brought down, one on each side of the deltoid, 
to the upper part of the board, the extremities being 
made to pass through a mortise, perforated in each 
board, in order to be knotted underneath. 

" The bands for fixing, and the traction bands, may 
then be adapted according to the principles of the 
system. 

" With respect to the suspension, in such a case, 
it may be made either from the ceiling, or the top of 
an ordinary bed ; or if the hospital-bed be employed, 
as described hereafter, from the Suspension-Bar attach- 
ed thereto. A precaution perhaps not unnecessary to 
be given, w^ith regard to the cushion is, that this 
should be of sufficient length to allow of its being 
turned downwards at its upper part, in order to pro- 
tect the axilla from the pressure of the extremity of 
the board." 

This last apparatus will, of course, be equally 



160 MAYOR'S SYSTEM. 

applicable to fractures of the humerus, if complicated 
with severe injuries of the soft parts, but where a 
carved splint, as spoken of hereafter, can be obtained, 
it offers such advantages as must prevent frequent re- 
course being had to this of M. Mayor. 

HYPONARTHECIA FOR THE TREATMENT OF FRACTURES 
OF THE LOWER EXTREMITY. 

" This consists of a straight board, furnished with 
a cushion, and suspended, something in the manner 
of a scale-beam, from the ceiling or top of the pa- 
tient's bed, by means of cords ; its object being to 
give support to a fractured limb, and allow of lateral 
movement. 

'' The only thing which distinguishes this from 
other kinds of apparatus, is the suspension. The first 
thing to be shown, is the method of constructing it, 
and the advantages to be derived from its employ- 
ment ; the next, its adaptation to the limb according 
to the nature of the injury. 

CONSTRUCTION. 

" A thin board must be procured, proportioned in 
length and breadth to the size of the limb, as in 
Figure 130 ; it should be a trifling degree broader, 
and a few inches longer than the limb. Thus, for 
fractures of the leg it should extend from the bend of 
the knee to three or four inches beyond the heel. 
This board should be covered by a cushion, of its 
own magnitude, made of oat-chafT, bran, cotton, hair, 
tow, or, in short, of anything that could answer the 
same purpose, and be readily procured : and it should 
hav€ sufficient firmness to afford a plane of some re- 
sistance to the limb, and yet be capable of moulding 
itself exactly to its form. A hole is to be pierced 
near each of the angles of the board for the passage 
of the suspension cord, as at c. Each end of the 



MAYOR'S SYSTEM. 



161 



Fig. 130. 




cord is then to be introduced through the correspond- 
ing holes at one extremity of the 
board from below upward, and 
after being drawn to the same 
length, passed from above down- 
ward through the holes of the 
other extremity, and firmly knot- 
ted. The cord will thus form 
two parallel bows of equal length, 
which, by being held at the mid- 
dle, will suspend the board as a 
perfect plane, or allow of its re- 
ceiving more or less inclination 
either way, according to the dis- 
tance, on one side or other of 
the centre, upon which the point 
of support is made to act- The 
support here spoken of, con- 
sists of another cord, one end 
of which is to be carried through a staple driven 
into the ceiling, above the injured limb, and the 
other made to pass under the collected bows. By 
pulling, in contrary directions, the extremities of this 
second cord, the board may be elevated to the neces- 
sary degree ; and by knotting them, the elevation 
thus obtained, steadily preserved. 

"Instead of the staple, it is better to employ a 
pulley, if it can be had, as seen in figure 131. A 
pulley would likewise be found more convenient for 
the connexion of the perpendicular and transverse 
cords, as seen in the figure at B. The first of these 
pulleys will afford greater facility in the elevation of 
the board, while the second will serve to give it the 
due degree of inclination, with but little effort, and 
without occasioning the slightest shock. 

" As the free sliding of the cords would be detri- 
mental to the treatment of this case, from the circum- 
stance of the board being liable to alter its position 
11 



162 



MAYOR'S SYSTEM. 



by the least movement of the patient, it is advisable 
to tie the two bows together near the pulley, and 
introduce between the latter and the ligature a small 
splinter of wood, which will naturally prevent the 
bows from retrograding. 




'' These preliminary arrangements, with the excep- 
tion of the introduction of the splinter, or foot-board, 
should be made before the limb is placed upon the 
board, in order that it may be immediately elevated 
when the former is applied upon the cushions. Care 



MAYOR'S SYSTEM. 163 

also should be taken to arrange beforehand the pa- 
tient's bed, by pressing it down at the part corre- 
sponding to the apparatus, in order that his horizontal 
movements may not be interrupted. As soon as the 
limb has been elevated to a certain height, it is advi- 
sable to place a pillow underneath the board, which 
should remain there till the fracture is reduced, and 
the position, &c., of the limb conveniently arranged. 
This apparatus, when isolated, yields to the slightest 
impulse imparted by the patient in his movements, 
without occasioning either shock or pain. 

" The facility which patients have of moving them- 
selves in this way is so great, that, as M. Mayor has 
remarked, they may be seen changing their position 
with the utmost facility, obeying, through means of 
the common utensils, the calls of nature, and even 
gliding upon another bed of equal height. 

^' Nevertheless, as may bereadilyconceived, it would 
be imprudent to permit them to indulge in any incon- 
siderate movements, as this would occasion and keep 
up in the osseous fragments a mobility that would 
become an obstacle to their consolidation. When, 
therefore, it is found impossible to suppress the indul- 
gence of such imprudent movements, the surgeon must 
have recourse to the bandage of Scultetus, with the 
aid of splints, or else to the carved splint, to be spoken 
of farther on. 

'* It may thus be seen, that in fractures of the leg, 
w^here the suspension apparatus presents the most ad- 
vantages, a simple board suffices, if it extends from the 
bend of the knee beyond the heel. A simple board 
arranged in the same manner, and which, departing 
from the tuberosity of the ischium, would pass a few 
inches beyond the heel, would also be equally suffi- 
cient for a fracture of the shaft of the femur, if it was 
considered proper to place the limb in an extended 
position, upon its posterior face ; but for those sur- 
geons who prefer the demi-flexion of the leg upon 



wmm 



164 



MAYOR'S SYSTEM. 



the thigh, and the latter upon the pelvis, the follow- 
ing apparatus becomes indispensably necessary. Two 
boards must be procured, the one precisely similar to 
that called tibial, of which mention has been already 
made and represented in Fig. 131 ; the other/emora/, 

Fig-. 132. 




I 



as in thisfigure,extendingfrom the ham to the ischiatic 
tuberosity, and articulating with the preceding, either 
by means of hinges, or simple tapes, which should 
pass through the holes with which the extremities of 



MAYOR'S SYSTEM- 165 

these boards are pierced, and be knotted underneath. 
The suspension of this double inclined plane is effect- 
ed in the same manner as the simple tibial board, 
with this difference only, that the two bows are ex- 
tended from the superior extremity of one of these 
boards, to the inferior extremity of the other. But 
in order to form the two inclined planes which are to 
support the limb in demifiexion, a small cord should 
be passed from below upward, through one of the 
holes of the upper extremity of the tibial board, as 
in the figure, across the point of support, and thence, 
from above downward, through the other hole of the 
same extremity, under which the two ends should be 
knotted together. In this way, the extremities of the 
two boards, corresponding to the bend of the knee, 
maybe made to describe an angle, more or less acute, 
according as the limb is required to be placed in a 
greater or less degree of flexion. 

'' When position alone is sufficient to maintain the 
fractured extremities of the bone in apposition, and it 
is indispensably requisite to exert continued extension, 
or, in short, when more solidity is required to be given 
to the apparatus, the femoral board should be shaped 
out at its internal and superior angle, and furnished 
with a belt, which will be spoken of farther on. 

" The boards thus arranged, are not only useful in 
fractures of the shaft of the femur, but also in the 
treatment of fractures of the neck of that bone ; as 
they fulfil perfectly, in presenting two inclined planes 
for the flexion of the thigh and leg, the indication of 
the pillows of Sir Astley Cooper, and the machines of 
Sir Charles Bell, Earle, Delpech, &c. ; which have 
the inconvenience of being much more complicated, 
and consequently of less easy and general application, 
particularly in places distant from large towns. In 
short, one of the advantages for which the suspension 
apparatus is deserving of being made known, is its 
simplicity, and its possibility of being constructed at 



166 MAYOR'S SYSTEM. 

all times, and in all places. In country practice, says 
M. Mayor, in isolated districts, every portion of this 
apparatus may be readily procured without occasion- 
ing the least embarrassment to the surgeon. 

" For myself, I may say," continues this gentle- 
man, '^ I have never experienced the slightest diffi- 
culty. I have sometimes substituted any common 
bands, when the proper cords failed me ; I have nailed 
these to the board when I have had no instrument to 
bore the ordinary holes ; I have employed nails for 
screws, and to form the directing bands, tow, wool, 
or rags ; these last materials, as also bran, saw^dust, 
moss, and even soft hay, have served me in construct- 
ing my cushions for the boards ; the bark of a tree, 
moistened leather, the binding of an old book, have 
supplied the place of pasteboard ; and rope-ends, skin, 
or strong cloth, have not unfrequently replaced the 
metallic hinges. 

''The double-boardedapparatus,it maybe observed, 
will be found extremely useful in the case of fracture 
of the leg, with tendency to displacement, more espe- 
cially when this occurs near the knee-joint, from the 
impossibility of applying the garter, {jarretiere,) one 
of the directing bands of which, mention will be made 
farther on. 

" Although particularly applicable to fractures of 
the limbs, the suspension apparatus of M. Mayor may, 
under other circumstances, be of important use. It 
will readily be conceived how great might be its 
utility in any painful diseases seated upon one or 
other of the limbs, as well as in certain white-swell- 
ings, in arthritic and rheumatic tumefactions of the 
foot, or in any other serious affections of the knee, or 
of the articulation of the foot and leg. Its use might 
be extended to the treatment of transverse wounds of 
the thigh, or of the tendo-Achillis, for which the most 
perfect immobility is indispensable. There cannot 
be a better means, so long as the immobility of the 



MAYOR>S SYSTEM. 167 

fractured part is insured, of allowing the patient to 
vary his position in bed. 

ADAPTATION. 

" It is not sufficient, although assertions of this kind 
have constantly been made, to place a fractured limb, 
after its reduction, upon an immoveable plane, in 
order to effect the cure. If this were true, for very 
simple cases, which would be but exceptions, if, for 
instance, in the majority of cases of simple fracture 
of the femur, a convenient position and a retentive 
bandage might be made to replace all those compli- 
cated machines, which do more honour to the me- 
chanical knowledge of their inventors, than to their 
knowledge of physiology ; it is not the less certain, 
that other means are required also, to maintain the 
fractured extremities of a bone in perfect contact, to 
overcome the involuntary as well as the spasmodic 
contractile efforts of the muscles, and the indocility 
of the patient. But between these indications, and 
the necessity of violently extending in contrary w^ays 
the two extremities of a limb, by mechanical powers 
which resemble only the rack of the inquisition, there 
is as wide a distance, as between the glossocome of 
the ancients and the simple pillows of Sir Astley 
Cooper : the surgeon who does not dare to expose 
himself to the dangers of the first, or to the insuffi- 
ciency of the second, has recourse in cases to the ex- 
tension apparatus of Dessault and others, which are 
not, however, free from inconvenience, but more often 
to the simple directing bands of M. Mayor, to which 
the only real objection that can be made is, that they 
are sometimes insufficient. 

" In the greater number of cases of fractured limbs, 
the fragments face each other ; whence the necessity, 
of exerting pressure in the direction of their diameter, 
if the displacement exist in relation only to the axis 
of the body of the bone, or of pulling at the same time 



168 



MAYOR'S SYSTEM. 



at the lower fragment, if the displacement is longitu- 
dinal, or in other words, if the broken ends overlap, 
in order to effect their coaptation. The hands alone 
of the surgeon and assistant are sufficient to fulfil ef- 
fectually these indications ; but as they are only tem- 
porary means, recourse must be had, in order to ren- 
der the effects permanent during the whole time ne- 
cessary to the consolidation, to the aid of an intelli- 

Fig. 133. 




gent machine, if such an expression may be used, 
which, in accomplishing this end, will in no respect 
inconvenience the patient. 

'' Let the fracture of a leg be taken as an instance ; 
if it be of such a nature as not to exact the continued 



MAYOR'S SYSTEM. 



169 



extension of the limb, and position alone suffices to 
maintain the broken ends in apposition, the surgeon 
has only to confine himself to the application, below 
the knee, of a tie or garter, the central portion of 
which has merely to be applied upon the anterior, or 




one of the lateral faces of the limb, and its ends at- 
tached either separately on each side, or together, on 
the outside or inside of the board. Fig. 134. The object 
here in view, as will be easily perceived, is to fix 
the limb upon the board and give a due direction to 
the superior osseous fragment. The garter, like all 
the other directing bands,may be made of a bit of 



170 MAYOR'S SYSTEM. 

common roller, or a longitudinal compress, but M. 
Mayor prefers those he ordinarily employs. These 
directing bands, the form of which may be seen in the 
figure, should be thick and soft, in order to preserve 
their shape, and prevent them from exercising a 
painful pressure. They should be constructed of 
two pieces of linen cloth, from three to five inches 
wide at the middle, with a layer of wadding, char- 
pie, tow, or wool, interposed between them ; to 
the two extremities of these bands should be sewed 
tapes of convenient dimensions, or padded hand- 
kerchiefs w^ill do as well. The figure indicates so 
clearly the manner of disposing them, that it is un- 
necessary to dwell upon them longer here : the place, 
however, they are to occupy upon the limb, will be 
spoken of by-and-by. 

*' When these simple bands are found insufficient to 
fix the limb solidly upon the board, or when it is ne- 
cessary, in order to maintain the fracture reduced, to 
exert continued traction on the limb, the following 
pieces must be added. To the inferior extremity of 
the board above spoken of, a foot-support is to be 
adapted, of the shape of a ladder, as in Figure 130, 
by means of mortises, a a, pierced in the former to 
receive it ; it should be from eight to ten inches high, 
and form with the board an angle of about eighty 
degrees. 

'-'- The object of this foot-board is to fix the heel-strap 
or ordinary gaiter, which, on one hand, embraces ac- 
curately the instep, heel, and malleoli, and on the 
other, is attached by means of the two tapes, which 
terminate it, to one of the sides of the ladder, ac- 
cording to the direction desired to be given to the 
limb. 

** Thus, by means of the gaiter on one hand, and the 
foot-frame and heel-strap on the other, the elongation 
of the limb may be produced, and the overlapping 
of the fractured ends effectually prevented. The 



MAYOR'S SYSTEM. 171 

extension being made, is maintained by the heel- 
strap, and the counter-extension by the garter, or band 
at the knee, without taking into account the weight 
of the body, and the fixture of the limb upon the ap- 
paratus ; while the heel-strap, by fixing the foot, 
prevents rotation, inwards or outwards, of the lower 
fragment. 

'' But this alone is not sufficient to restore the limb 
to its natural form when the fragments are displaced 
in respect to the diameter of the bone ; and although 
the shortening of the bone has been provided against, 
nothing has yet been done to maintain the fractured 
ends in apposition. The following is the manner in 
which this indication is to be fulfilled ; instead of 
resorting, as is generally the case, to the uniform 
pressure exerted by the eighteen-tailed bandage, or 
that of Scultelus, with splints applied upon the soft 
parts that surround the ends of the bone, M. Mayor 
has recommended a means much more simple and 
more efficacious, and one which offiirs, besides, the 
advantage of not covering in with the apparatus the 
part of the limb at which the fracture is seated ; per* 
mits the surgeon also to visit it as often as he pleases, 
without the help of an assistant ; and to remedy the 
displacement, if any such should have occurred, as 
well as to dress the wound, should one exist, without 
meddling with the apparatus. The means in question 
consists in placing upon the part of the limb toward 
which the end of the bone is directed, and where it 
makes projection, the centre of a directing band, as 
Fig. ]33 (B) ; and fastening the extremities to the 
opposite side of the board ; care being taken, how- 
ever, to see that the fracture is properly reduced. 
Two bands, which act in opposite directions, are oc- 
casionally necessary, but more frequently the desired 
effect is obtained by one alone. The middle of the 
band should be applied upon the most convex part 
of the deformed limb ; one of its extremities is to be 



m 



172 MAYOR'S SYSTEM. 

passed immediately under it, the other over, and both 
drawn with sufficient force and fastened to a peg, 
inserted at the side of the board, which corresponds 
to the concavity of the limb, or in default of this, to 
a mortise pierced about this spot ; they may be even 
nailed at once to the board. 

" The directing bands should not be placed until the 
heel-strap and garter are adapted, the latter being 
fixed to the board upon the opposite side to that to- 
ward which the neighbouring band 
Fig-. 135. is to be directed ; without attending 

to this, the two extremities of the 
limb would be found to yield to the 
inverse tractions of the bands. The 
disposition of these several pieces 
is seen in the Figures 133, 134. In 
comminuted fractures with extreme 
tendency to displacement, a piece of 
pasteboard should be applied upon 
the anterior part of the limb, as in 
Fig, 135, the notched end being in- 
tended to touch the front of the foot. 
" To fix the femoral board more solidly, the sur- 
geon should apply the large quilted band, or padded 
handkerchief before spoken of. This band should 
be of sufficient length to pass as a belt round the 
body, and terminate by a strap, to be attached to a 
strap and buckle, fixed to the external and superior 
part of the board. This band serves at once as a 
body-bandage and perineal strap ; it passes first of 
all upon the groin of the injured side, then round the 
corresponding ilium and along the back, and is re- 
turned over the pubes to the upper part of the frac- 
tured thigh, where the buckle, fixed to the outer side 
of the board, receives it, or w^here, when this is 
wanting, it may be fastened to some other convenient 
point of attachment. This belt, which, as may be 
perceived, tends to fix securely the femoral board 



|ii 



MAYOR'S SYSTEM. 173 

upon the pelvis, is employed with the notched por- 
tion of the board, against which the tuberosity of the 
ischium rests, to produce the counter-extension, or, 
in other words, the resistance necessary to meet the 
tractions of the heel-strap ; while the latter acts at 
the same time upon the limb, which it elongates, and 
upon the board which it pushes upward, first beneath 
the ham and then upon the ischiatic tuberosity. 
Lastly, it is this portion of the apparatus which per- 
forms the greatest part in the effort ; but as it is aided 
firstly by the weight of the limb, which, placed upon 
an inclined plane, tends to descend ; and secondly, 
by the effort itself, which tends to elevate the bend 
of the knee, there can be no reasonable apprehension 
of the formation of sloughs or excoriations, such as 
the ordinary machines for continued extension too 
frequently produce. 

*' This apparatus appears to unite all the qualities 
necessary for the reduction and consolidation of frac- 
tures of the neck of the femur. 

" To resume ; when it is required to maintain a re- 
duced fracture of the femur, of whatever nature it may 
be, whether situated near the knee, or in the shaft or 
neck of the bone, whether simple or complicated, with 
or without obliquity of the fragments, the thigh and 
leg are to be extended over the inclined plane, well 
cushioned, the belt applied round the thigh and pel- 
vis, and the foot attached to the ladder or foot-board 
inserted in the lower end of the tibial board. A 
large quilted band, or several handkerchiefs, embrace 
the whole apparatus to confine the limb upon the 
board, when there is no deformity ; or the bands of 
direction, already described, made use of w^hen the 
limb is curved, or there is any tendency to curvature. 

" With a view of raising patients in bed, when suf- 
fering from injuries to the lower extremities, M. Mayor 
proposes a Clinical Frame, which, from its simplicity, 
has many advantages over the complicated machinery 



174 MAYOR'S SYSTEM, 

of Earle, Jenks, &c., and may be advantageously 
used, especially by army surgeons, as it offers an ex- 
cellent bed, under even ordinary circumstances, being 
more steady, and not liable to the objections of an 
ordinary hammock. 

In speaking of it, he says : — ''It is, doubtless, 
highly gratifying to have at our service, as practitioners, 
a number of easy and convenient kinds of apparatus, 
as well as appropriate and salutary therapeutic agents ; 
but there are circumstances in w^hich, if we have the 
latter at command, the former are by no means so 
much in our power ; whence it happens, that we are 
occasionally called in, under circumstances so per- 
plexing, nay, so truly desperate, that we are content 
with positive inaction, rather than allow our interfer- 
ence to add to the patient's sufferings. 

*' A large number of serious affections are daly met 
with which not only compel the patients to keep their 
bed, but even place them beyond the possibility of 
being removed from one part of the bed to the other, 
without their being subjected to the most excruciating 
pain, or even to actual danger. Whether they repose 
then upon a bed of eider-down, or are stretched upon 
a hard paillasse, these unfortunate individuals soon 
experience the want of having their bed better ar- 
ranged, and of being replaced in a position more sup- 
portable. They are excoriated at all those places 
where the bones project, as at the sacrum and the 
hips ; the skin, deprived of its subjacent fatty tissue, 
constantly and powerfully pressed against the bones, 
soon becomes irritated, and ultimately sloughs; 
whence result those deep and extensive wounds, 
which, incessantly exposed to an invariable, and one 
might almost say corroding, pressure, to the difficul- 
ties attendant upon their dressing, and, still worse, 
to the continual contact of urine and fsecal matter, 
sometimes finish existence of themselves, or rapidly 
abridge its duration. 



MAYOR'S SYSTEM. 175 

" For the purpose of averting these serious incon- 
veniences, various mechanical beds have been in- 
vented, the most ingenious of which tend to elevate 
entirely, and with great gentleness, the unfortunate 
sufferers whom it would be impossible to move with 
the hands or any other means without occasioning 
the most heart-rending cries. 

" It will be readily conceived, that the hands of 
one, two, or even three persons, are wholly insuffi- 
cient to support the entire body of an adult ; that the 
parts w^hich are not sustained must be put upon the 
stretch, while the others are pushed up, and that, 
from this unequal manner of action, the most excru- 
ciating pains ensue. And let it be, moreover, re- 
marked, that the fingers do injury from their hard- 
ness ; w'hile, in addition to all this carrying to and 
fro of the body of the sufferer, the most disagreeable 
shocks are constantly occasioned, which infinitely 
augment his already intolerable pain. In point of 
fact, patients in general prefer supporting the w^hole 
of the serious inconveniences allied to their actually 
invariable and painful position, rather than expose 
themselves, by this lifting about, to absolute tor- 
tures ; more especially, when this has to be effected 
frequently. 

" Circumstances so melancholy have necessarily 
had the effect of awakening the solicitude of practi- 
tioners, the industry of patients themselves, and the 
compassion of those who are about them to contri- 
bute, if possible, to the palliation of such tortures, or 
at least to attenuate some of their more fatal conse- 
quences. But it has been more particularly in favour 
of the minority, that is to say, of the opulent, that 
such efforts have been crowned with success ; the 
lower orders of society still remaining without the 
pale of benefits arising from the invention of ma- 
chines calculated to be of avail in circumstances such 
as those just pointed out. The reason of this is 



176 MAYOR'S SYSTEM. 

evident ; the means indicated, and known under the 
title of Mechanical Beds, are so complicated and so 
costly, that they can only be within reach of persons 
in easy circumstances ; and even in hospitals, these 
beds are generally few in number, and their use very 
limited. 

" So great, therefore, is the difficulty of obtaining 
these different kinds of apparatus, and still more the 
difficulty of adapting them to the exigencies of the 
most numerous classes of the community — classes 
which, be it observed, are the most constantly ex- 
posed to affections demanding contrivances of this 
kind — that it has been of the utmost consequence to 
consider other means, than such pieces of mechanism 
present, and to seek for what seems to have been, 
hitherto, wholly lost sight of, namely, a contrivance 
within the reach of every individual, and applicable 
in ev^ery circumstance. This desideratum, M. Mayor 
thinks, will be found in his Clinical Frame, which 
he thus describes. 

*' The first things to be sought for are two narrow 
boards or poles about the length of the patient, and 
two crossbars of the same nature, of about a yard 
only in length. With these four pieces of wood, 
which may be easily united at their extremities by 
means of nails, rivets, bits of cord or handkerchiefs, 
w^e shall be immediately in possession of a frame in 
all respects stout enough for the end in view. It 
now remains to fill up the intermediate space ; and 
recourse must here be had to bands of webbing : but 
if these should not be at hand, or at all events, should 
they be difficult to obtain, a few stout cravats would 
conveniently supply their place. Whether, then, the 
webbing bands or the cravats be employed, they must 
be arranged crosswise, fastened securely at their ex- 
tremities to the sides of the frame, and, above all 
things, possess sufficient strength to resist the weight 
of the patient when suspended in the air. Substi- 



MAYOR'S SYSTEM. 



177 



tutes for the above materials may be equally found in 
towels, napkins, sheets, or indeed in anything that 
would serve to constitute a bottom, soft, but yet suf- 
ficiently strong. After such simple data, it would be 
superfluous to point out how ingenious mechanics 
might modify the contrivance so as to prepare a frame 
more elegant, more in harmony with their own talent, 
their desire of gaining reputation, or indeed with the 
fortune of those who employ them ; on the contrary, 
it would be advisable to urge the necessity of pre- 
serving the same simplicity in the construction of this, 
which will be found in the means destined to effect 
its elevation ; for there will be quite enough of 
those who are ever on the alert to throw a species 
of luxury about a machine, who will believe that 
they have perfected this, when, from a simple and 

Fi^. 136. 




effective instrument, they will have converted it into 
a complicated one, despoiled of its best qualities. 

" To raise the frame, as well as the patient, who is 
supposed to be stretched upon its bottom, it would 
12 



178 MAYOR'S SYSTEM. 

be sometimes sufficient to employ two or three dex- 
terous persons, such as are met with in hospitals ; 
but in addition to the difficulty of finding such assist- 
ants, there will be always more or less inconvenience 
attending this operation when effected by the hands, 
in consequence of the shocks to which the frame will 
be constantly subjected, from the slightest deviation 
from a simultaneousness of action. It will, therefore, 
be found more convenient to have recourse to the 
means employed in the hyponarthecic suspension, 
and to apply to the whole body, that which so well 
succeeds when applied to a limb. 

" Thus, the four angles should be perforated with 
four holes, as in the Fig. 136, through which a strong 
cord will be run in order to form two kinds of parallel 
bows or arc-loops of suspension ; the one longitu- 
dinal, the other transverse ; the former corresponding 
to the sides, the latter to the extremities of the 
frame. 

" Recourse may also be had to one loop only, which 
will give to the frame the kind of tilting (jeu de bas- 
cule) observed in the beam of a scale. Movements 
of this kind are occasionally of importance, as when 
it is desired to raise the upper part of the body much 
above the horizon, or even the lower part alone. 

" One strong vertical cord, firmly attached, and 
passing through a pulley, will suffice for the elevation 
of the frame charged with the patient, and must be 
arranged in the same manner as for the hyponarthecia 
of the extremities. Thus, in the dwellings of the 
poor, the ceiling is usually provided with large beams ; 
nothing, therefore, will be found more easy than to 
arrange properly the staples or pulleys. Recourse 
may be equally had to a suspension bar of the kind 
represented in the figure and placed at the head of 
the bed. But when these resources fail, or cannot 
be employed without some disadvantage, let that be 
remembered which is done by certain mechanics, 



I 



MAYOR'S SYSTEM. 179 

particularly masons, when they desire to lift a heavy 
weight. The tripod^ called generally the triangle, is 
the most easily constructed, the most firm, and in all 
respects the most convenient that can be employed 
for the object here proposed. This tripod, seen in 
the figure, should have a pulley attached to the iron 
hook observed at its upper part or point of union, in 
order to receive the vertical cord destined to raise the 
frame ; and thus provided, should be stretched across 
the bed. 

" In order to render the ascent of the frame per- 
fectly gradual and easy, the vertical cord should be 
made to pass round a cylinder, fixed to two of the 
legs at their upper part, which may be turned either 
by a winch, or, if provided with holes and a small 
handle, as a capstan. Instead of this, if the free end 
of the vertical cord, after having passed through the 
pulley, be firmly secured to one of the legs of the 
tripod, the above effect may be accomplished by 
means of a strong stick, which is employed to twist 
the cord, and which, by shortening it at each turn, 
elevates the frame. 

" But a still easier method is to employ a simple 
lever of the first power, — a pole, for instance, — 
whose fulcrum should be beside the bed, and to one 
end of which should be fastened the arc-loops them- 
selves, as seen in the figure, or, what is still better, 
the vertical loop, which will permit, during its ele- 
vation, the frame to be better balanced : in lowering, 
therefore, the other end of the lever, the ascent of the 
frame may be regulated with precision. The fulcrum, 
thus placed between the power and resistance, may 
be simply a rope end's made into a loop, and either 
firmly attached to the ceiling, or else to the tripod, 
which, in this case, instead of being stretched over 
the bed, should be placed beside it. 

'' With the ordinary hyponarthecic loops attached 
to the Clinical Frame, which will allow of the point 



180 MAYOR'S SYSTEM. 

being varied where they are taken up by the vertical 
loop, we obtain, with the greatest facility, the power 
of elevating this frame in any direction we may 
choose, whether completely horizontal, or with an 
inclination towards either of its extremities or either 
of its borders : an advantage which will not be with- 
out its utility on particular occasions. 

" It will be hardly necessary to observe that, in 
order to obtain these effects, it suffices merely to place 
the vertical cord at the centre of gravity itself of the 
frame, or more or less beyond this, in the direction 
either of the head or feet, and to make, for producing 
lateral inclination, the arc-loop shorter on one side 
than on the other. The arc-loops, however, ought 
to be collateral, for all these little advantages would 
be far less easily obtained, were the cords, which 
perform the office of loops, placed transversely at 
either of the extremities of the frame. 

*' Like all frames destined for a clinical use, that 
just described may rest continually in place, in order 
that it may be raised at the moment desired, without 
previous preparation ; that is to say, the patient should 
repose upon the bottom of the frame itself ; or else this 
elevation may be applied only at the instant when oc- 
casion may require it. In the first case, we should 
be careful that the bands or the pieces of cloth which 
constitute the bottom of the frame do not annoy the 
sufferer, and are preserved as clean as possible. This 
will not be difficult if preference be given to large 
pieces of stout cloth, which will occasion so much 
the less inconvenience, as they may be stretched at 
will, without forming any incommodious folds. 

" It will be clearly seen, moreover, that, with this 
disposition, the surgeon may readily expose the ulce- 
ration, and manage the application of dressings, by 
displacing from the bottom of the frame that portion 
which otherwise masks the affected parts. 

*' When, on the other hand, it is found advisable to 



MAYOR'S SYSTEM. 181 

apply and elevate the frame several times, recourse 
should be had to the webbing bands, which, by means 
of a broad, thin, pliant piece of wood, may be glided, 
at the very moment, under the patient, much in the 
same manner as we should change the bandelettes in 
the apparatus of Scultetus. These bands, already at- 
tached to one side of the frame by one of their extre- 
mities, are then brought to the opposite side, where 
they are fastened, by means of their free extremities, 
through the intermedium of ribbands, buttons, or 
buckles. This simple and easy means of gliding the 
bands under the patient, without at all incommoding 
him, and thus interposing between the bed-clothes 
and himself some sort of bottom proper to sustain him 
when elevated, would naturally suggest a still more 
simple support, namely, cravats or oblongs, of what- 
ever tissue they may be composed, or of whatever 
breadth it may be thought proper to afford them. 
The Clinical Frame may not only be regarded as a 
species of hyponarthecia, destined to sustain momen- 
tarily the entire body in any manner, or in any direc- 
tion desired to be imparted, but, being moveable, it 
will be seen to offer one very precious resource in a 
circumstance of the most important nature. Allusion 
is here made to the frightful sloughing sores common 
to the lower and back part of the body, and which 
the pressure against the bandelettes renders insupport- 
able, and tends constantly tc exasperate. Many are 
the means, without doubt, employed to attenuate this 
horrible pressure ; yet they not only most often fail, 
but are difficult to procure, to maintain in place, and 
preserve in a proper state of cleanliness. The Clini- 
cal Frame, then, with very little additional trouble, 
averts this inconvenience in the following manner: 

" Let the individual be extended over the bands 
placed transversely behind his back, and let us sup- 
pose that these bands are properly stretched from one 
side of the frame to the other ; it is clear that the poor 



182 MAYOR'S SYSTEM. 

sufferer will press upon them all with his entire weight. 
But if we detach those bands which correspond to the 
ulcerations, and if, at the same time, we remove suffi- 
cient of the hair, wool, or straw of the mattress which 
exists under the bands we have just placed aside, we 
shall immediately obtain a sort of hollow or depres- 
sion, in which the ulcerated surface will be but very 
slightly touched. It will be even possible to afford 
such depth and extent to this depression that the 
affected parts remain, as it were, in the air, in a com- 
plete state of isolation. In short, the bands, placed 
above and below the seat of ulceration, will sustain 
the body with great exactness, and will leave the 
sore open, and at that degree of elevation which may 
be judged necessary, to subtract it more or less, from 
the pernicious influence of the pressure we are striv- 
ing to avoid. 

*■' It may be, however, observed, that, instead of 
the excavation already spoken of, the mattress may 
be cut across, and of one mattress two smaller ones 
formed, which may be placed so as to allow of a suf- 
ficient space between them to guarantee the wound 
from pressure, according to its extent. 

" The Clinical Frame may, in campaign, admirably 
serve for a litter, or for the transport of the sick or 
wounded, as it possesses the advantage of the most 
simple form of construction, and of being made of 
materials to be found on all occasions. In this case, 
instead of webbing or other bands, to form the bottom 
of the frame, recourse may be had to simple cords 
covered with hay, straw, leaves, grass, pieces of cloth- 
ing, &c. When it is found necessary to have the 
litter stationary, nothing would be more easy than to 
adapt to it a tripod or triangle, which would possess 
two remarkable advantages ; firstly, in forming solid 
feet for the support of such temporary bed ; and, 
secondly, in forming a frame, proper to receive a 
blanket, or something of the kind, to serve for the 



I 



MAYOR'S SYSTEM. 183 

purpose of a curtain, and to protect the sufferer from 
the sun, rain, wind, &c. 

" Many other occasions might, doubtless, be found 
for the use of this frame when put into suspension. 
Serving as a sort of hammock, it would seem to invite 
officers to establish it under their tents, and would 
guarantee them from the humidity of the ground, 
from insects, and other annoyances inseparable from 
a bed placed directly upon the earth. The same 
may be said of it in a bivouac, where the triangle 
need only be covered by a cloak. 

" The suspension-bar, as seen in Figure 136, 
adapted to a common hospital-bed, has been already 
pointed out as a means of establishing the suspension 
of a hyponarthecic apparatus : it requires no descrip- 
tion, for the drawing will suffice to give the most 
correct idea of its construction. It will be seen 
therein to represent, however, only one-half of it, as 
the drawing of the other half would have interfered 
with the view of tlie tripod." 



i 



i 



I 



PART III 



CHAPTER I. 

OF THE APPARATUS FOR THE TREATMENT OF 
FRACTURES. 

GENERAL CONSIDERATIONS. 

The responsibility involved in the proper treatment 
of these injuries, renders them one of the most im- 
portant parts of the practitioner's duty ; as not to be 
able to set a broken limb, or reduce a dislocated bone, 
is enough to destroy all professional reputation ; the 
public in general not being able or willing to under- 
stand the distinction drawn between the duties of the 
surgeon and those of the physician. Indeed when a 
case turns out badly even in the hands of the most 
able surgeon, the friends of the patient, to use the 
language of Mr. Amesbury " sometimes think they 
can never injure his reputation sufficiently ; and 
though in many instances he is not at all deserving 
of blame, they usually load him with epithets of igno- 
rance, neglect and presumption. If we examine a 
little into this feeling we shall find that it is nothing 
more than what is naturally to be expected. Patients 
know nothing scientifically of the nature of frac- 
tures, or of the means made use of for their cure ; 
consequently they judge of the surgeon's ability ac- 
cording to the result of his case. If it terminates 
well, the surgeon has only done his duty ; but if the 
limb be deformed^ the patient will immediately say, 



m 



186 



TREATMENT OF FRACTURES. 



that the fracture was badly set, and be confirmed in 
this opinion by the observation of his friends, who 
seldom fail to find out cases to substantiate their 
belief." Yet important as the subject undoubtedly 
is, it would be foreign to a work of this kind, to 
treat of it in all its bearings, or consider its causes, 
and its physiological and pathological changes. 

We shall, therefore, in the consideration of this part 
of the subject, confine ourselves mainly to such points 
as are most connected with the treatment ; only hint- 
ing briefly at such general considerations, (especially 
as respects the causes of the defor- 
mity, and the indication to be ful- 
filled in the treatment,) as are 
concerned in the plans of practice ; 
referring those who wish a more 
minute knowledge of it, to the many 
articles to be found in all our works 
on Surgery. 



Fi9: 137. 



The Bones being intended for the 
support of various portions of the 
body, and acted on by the muscles, 
it follows that any solution of con- 
tinuity in their structure, must in- 
volve very materially the use of the 
part, and create deformity from irre- 
gular muscular action. The over- 
coming of this deformity, and the 
retention of the broken ends of the 
bone in such a position as will be 
most favourable to their union and 
subsequent usefulness, are then the 
first principles involved in the treat- 
ment. To prove this, a slight refer- 
ence must be made to the bond of 
union, or Callus. The first effect 
of fracture, being a division of the fibres of the 



TREATMENT OF FRACTURES. 187 

bone, with more or less laceration of the soft parts, 
inflammation must necessarily follow. This results in 
fortunate cases,in the effusion and organisation of lymph, 
which subsequentlybecomesbone, and by its extension 
beyond the fractured extremities, binds them together 
externally, (Fig. 137), until a more perfect union is 
effected within their extremities. This external matter 
or Provisional Callus, being that which is first formed, 
is of course that most directly implicated in the results 
of the means employed, the second, or definitive callus, 
not being completed till long after the ordinary dura- 
tion of the treatment. Certain circumstances, as rest, 
position, and the prevention of too high a degree of 
inflammation, or the excitement of the necessary 
amount where it does not naturally exist, are therefore 
essential to the cure, and the creation of these circum- 
stances, or the fulfilment of these conditions, consti- 
tute therefore the general principles of the case. As 
the proper fulfilment and comprehension of these, can, 
however, only be gained from an accurate knowledge 
of physiology, we can do little else than lay down 
the general means of fulfilling them. 

To accomplish these indications, we must, therefore, 
1st. Reduce the displaced ends of the bone ; 2d. Co- 
aptate and keep them reduced ; and 3d. Subdue the 
local inflammation, and combat the accidents that 
may arise from the means of treatment. 

1st. Reduction. — The first indication, or the re- 
duction of the displaced ends of the bone, is limited 
to such fractures as are accompanied by this deformity ; 
such as those of long bones surrounded by powerful 
muscles, or exposed to blows, which can act directly 
on either fragment. 

To accomplish this, we must resort to what istechni- 
cally known as Extension, and Counter-Extension, or 
the use of such means as tend to bring the bone to 
its original length. Extension, is the force applied to 



188 TREATMENT OF FRACTURES. 

that extremity of a broken bone which is furthest from 
the heart ; and Counter-Extension, that which exactly 
balances the extension, or prevents the whole body 
yielding to the force applied to the lower end of the 
limb. But in some instances, even in fractures of the 
extremities, as in fractured patella, olecranon, &c., it 
is improper, if not impossible, thus to make extension 
and counter-extension, and we are obliged to resort 
to position, or placing the muscles in a state of re- 
laxation, in order to accomplish our object. This latter 
point, position, has for many years been a disputed 
question among surgeons ; Pott, and many of the 
English school, contending for its advantages, w^hilst 
the French and American writers, advocated the more 
mechanical means of treatment; averring that position 
alone would prove injurious to most cases. Like 
most disputants, they carried their opinions to such 
extremes, as to injure all parties. That in many cases, 
extension is absolutely necessary to the reduction of 
a fracture, cannot be doubted, but that position is also 
not to be neglected, is equally indisputable. Take, 
for example, a fractured clavicle, the mere extension 
affected by carrying the shoulder outwards, would not 
relieve the deformity, without attention being also paid 
to its position of backwards and upwards. Again a 
fracture of the femur, or of the leg, would not be pro- 
perly reduced by mere extension and counter-exten- 
sion, unless at the same time, the position of the foot was 
looked to. The prudent practitioner should therefore 
bear in mind, simply the fact, that it is the force of mus- 
cular contraction that is to be overcome ; and whether 
accomplished in an extended or flexed position, by 
compression of bandages, or without them, not rest 
satisfied until he has accomplished his object. In 
fractures of the long bones, the weight of French and 
American authority is in favour of the extended posi- 
tion of the limb ; whilst the pupils of Pott and many 



TREATMENT OF FRACTURES. 189 

of the English surgeons, still prefer the flexed, especially 
in the treatment of those of the lower extremities. 

2d. Coaptation^ and keeping the hones reduced. — 
The accomplishment of these indications, is usually 
the result of the employment of certain forces, more 
or less directly, to the seat of fracture. Where two 
bones are parallel, and it is important to keep them 
at a certain distance, as in the bones of the forearm 
and leg, or 'where one fragment is liable to such irre- 
gularity of position as cannot be otherwise overcome, 
it becomes necessary for the surgeon to press upon 
them with his fingers, and mould them to the de- 
sired condition ; thus coaptating or setting the frac- 
ture. But where the deformity can be remedied by 
the action of muscles, it is better not to finger the seat 
of fracture, as the pressure of the soft parts on the sharp 
points of bone, might create such irritation, as would 
rather increase, than relieve the existing symptoms. 

As the muscles are, also, the motive powers of 
the body, and as they are attached to the bone, it 
follows, that even after the setting of a bone, any 
sudden action on their part would tend to displace it ; 
so that the common idea of a bone once set, being 
always afterwards in its proper position, is incorrect, 
the facts being most frequently the reverse, the 
attention of the surgeon to the state of the bone, 
being always required, at each dressing, until consoli- 
dation has taken place, lest the action of the muscles 
again displace it. In order to guard against this, 
various means, consisting of Splints, Cushions, or 
Junk-bags, Pads, Extending and Counter-Extending 
Bands, Palettes, or Hand Splints, Soles or Foot- 
Splints, Compresses, Pads, Slings, and Rollers, — 
the minute directions for the preparation and applica- 
tion of each of which, will be given in connection 
with the treatment of the particular fractures for which 
they are required. 



190 TREATMENT OF FRACTURES. 

3d. Combatting inflammation, and the accidents re- 
sulting from the means of treatment. — These, though 
placed last, are by no means the least important items 
in the treatment ; fractures being so generally the 
result of violence, that inflammation is very apt to 
ensue. This, provided it does not run too high, or 
involve neighbouring parts, need not be interfered 
with, a certain amount being necessary, as stated, to 
the formation of callus. But, if otherwise, the use 
of cold washes, and the anti-phlogistic system gene- 
rally, will be necessary to prevent its going too far. 

The combatting of the accidents resulting from 
the plan of treatment, will more frequently test 
the surgeon's skill, than any other portion of the 
case. Excoriations, ulcerations, bed-sores, and con- 
stitutional symptoms, such as fever, diarrhoea, &c., 
are all liable to complicate the case; and there are 
few of any experience, who have not felt the evils 
referred to. Every attention should, therefore, be 
given to the proper construction of the bed and of 
the apparatus ; to the room in which the patient is to 
be confined ; to diet, &c., &c. ; in order to guard 
against accidents, which sometimes will produce 
a result, that nothing but previous experience could 
have led any one to anticipate. In the plan of 
Pott, or the flexed position of the lower extremity, 
there may be sloughing and bed-sores ; in the ex- 
tended state of the limb, ulceration on both heel and 
perineum ; whilst paralysis, arrest of circulation, and 
excoriation, may follow the treatment of similar inju- 
ries in the upper limbs. As however these evils can 
only be hinted at here, or better referred to in each ac- 
cident, we shall, without further delay, pass to the 
treatment of particular fractures. 



FRACTURES OF THE BONES, ETC. 191 



CHAPTER II. 

OF FRACTURES OF THE BONES OF THE HEAD 
AND TRUNK. 

FRACTURES OF THE SKULL. 

The treatment of fractures of the skull being 
dependent on whether or not it is necessary to 
trephine, their particular consideration would not be 
proper here. We merely therefore state that in any 
case where it is necessary to retain dressings to the 
cranium, we would resort to the Recurrent Bandage of 
the Head ; the Single or Double T ; the Handkerchiefs 
of Mayor ; the Bandage of Galen^ or to the Sling of 
Four Tails ^ as before given. 

IN FRACTURE OF THE BONES OF THE NOSE. 

After the fracture has been reduced by the use of 
a probe introduced into the nostril to elevate the 
bones if they have been depressed, we may employ 
the Double T. of the JVose^ to retain the dressings to 
the part, or to the internal angles of the eyes ; and 
combat the inflammation of the nasal duct which 
so often supervenes, no means being required to keep 
the bones reduced after the fracture is set, as they 
are not liable to displacement from muscular action. 

IN FRACTURES OF THE LOWER JAW, 

Anterior to its angle, we may em- 
ploy J9r. Barton'' s Bandage ^ p. 72 
with the use of a paste-board 
splint, made as in the figure, like 
the body of a sling ; or the Sling 
of the Chin J as before mentioned, 
or the Bandage of Dr. Gibson, 
which is composed as follows : — 




192 



FRACTURES OF THE BONES 



GIBSON'S BANDAGE FOR FRACTURE OF THE JAW, 

Is composed of a roller, five yards long and two 
inches wide, and of a compress and splint, if ne- 
cessary. 

In its application, after having carefully examined 
the injured parts, and replaced any of the teeth that 
may have been deranged, we run the fingers along 
the margin of the jaw, in order to mould it into its 

proper shape. Then 
Fig. 139. closing the mouth firm- 

ly, make the lower teeth 
press fairly upon the 
upper, and place a 
compress of moderate 
thickness under the 
fractured portion, where 
it should be held by an 
assistant. The sur- 
geon next takes the 
single-headed roller, 
and commencing on 
the top of the head, 
passes it by several turns down the side of the face, 
under the jaw, and over the compress ; after the third 
turn of this kind, he makes a reverse on one temple, 
so as to run off perpendicularly and surrounds the 
forehead and occiput by circulars of the vault of the 
cranium. On the third of these turns, pass from the 
occiput obliquely over the back of the neck, and 
under the ear, to make three circulars of the chin 
and neck ; from the neck pass obliquely upwards, 
to go circularly round the forehead, and place pins 
at each turn. If the turns are likely to slip, fasten 
a small strip on the forehead, and carry it over the 
vertex to fasten it to the turns on the neck, and thus 
secure them more perfectly as seen in Fig. 139. 

During the treatment of fracture of the jaw, the 
patient must be fed on soft, semi-liquid food, and not 




OF THE HEAD AND TRUNK. 193 

allowed to speak ; but there is no occasion for in- 
serting a piece of cork between the teeth, or extract- 
ing any of them, as there is usually enough space 
between them as they stand, to enable any one to suck 
food into the mouth. This fracture, under favour- 
able circumstances, consolidates in four or six weeks, 
but the patient should not eat hard or tough 
articles for some weeks afterwards ; for obvious rea- 
sons. 

FRACTURES OF THE VERTEBRAE, 

Require no apparatus. Our attention must here 
be mainly directed to the use of the catheter and 
of enemata ; directions for which will be given here- 
after. An important point to be recollected in these 
injuries is, not to turn the patient on his belly in 
order to examine the back, but to turn him only on 
to his side ; for as the abdominal and intercostal 
muscles may be paralysed by the injury, the dia- 
phragm alone can act in respiration ; but in order 
that this may descend, the abdomen must bulge out, 
so as to allow of the descent of the bowels and ex- 
pansion of the chest. If, then, the patient is kept 
for a length of time on his belly, there is not suf- 
ficient force in the diaphragm to do this, as it has to 
overcome the resistance made by the weight of the 
body on the bed, consequently, if the examination 
is tedious, the patient will run the risk of being suf- 
focated. 



IN FRACTURES OF THE STERNUM, 

The indications are, to prevent deformity from the 
projection, or depression of the fragments ; to keep the 
chest at rest, and oblige the patient to breathe by the 
diaphragm and abdominal muscles. These may be 
very well fulfilled by placing a compress over the 
part, and confining the chest by the Crossed Bandage, 
13 



194 FRACTURES OF THE BONES 

or by the Spiral of the Chest, as has been before 
shown. 

FRACTURES OF THE RIBS, 

Are to be treated on the same principles as those 
of the sternum, the compresses being over the parts, 
if the fragments project externally ; but over the 
ends of the rib, if internally. These compresses and 
the whole chest, are to be confined by the Spiral 
Bandage of the Chest, (Fig. 41,) which should be 
drawn very tight. 

FRACTURES OF THE PELVIS, 

Require no other apparatus than a broad bandage 
of the abdomen and pelvis ; there being here, little or 
no tendency to deformity, owing to the attachment of 
the muscles. 



FRACTURES OF THE CLAVICLE, 

Are treated by several kinds of apparatus, all 
having for their object the keeping of the shoulder 
upwards, outwards, and backwards. It is necessary 
that it should be kept upwards, in order to bring 
the fragments to the same level ; outwards, to pre- 
serve the proper length of the clavicle, keep the arm 
at its proper distance from the sternum, and preserve 
the pectoral space ; and backwards, to bring the 
bones into the proper line in front. The first means 
to be shown of doing this, is the old and widely 
known — 

APPARATUS OF DESSAULT. 

This is composed of three single-headed rollers, 
eight yards long, and two and a half inches wide ; of 
a pad of the length of the humerus, and four inches 



OF THE HEAD AND TRUNK. 



195 



Fig. 140. 




thick at its base, made in the shape of a wedge by- 
folding muslin on itself, 
so as to form a compress 
graduated from one end, 
as before shown, and 
then coveredwith a piece 
of muslin; — of a com- 
press to go over the 
broken bone ; of a short 
sling to support the fore- 
arm; and of a piece of 
muslin sufficiently long 
and wide, to surround 
the chest, arm, and bandage, and keep the whole 
dressing in its place. 

These being prepared, and the patient either seated 
on a bench, or chair with- 
out a back, or else stand- -f'-f- ^^^• 
ing, an assistant is to 
elevate the arm of the 
injured side, and carry it 
off at right angles to the 
body ; whilst the surgeon 
places the pad in the ax- 
illa, the thick end up- 
wards, where it is to be 
held by the assistant. The 
initial end of the first 
roller, is then placed on 
the middle of the pad, 
and two or three circular turns of the chest made, in 
order to fix it, when the roller should be carried up 
over the front of the thorax ; over the sound shoulder ; 
under this arm-pit to make a semi-circular turn on 
the front of the chest ; over the pad ; round on the 
back ; over the sound shoulder ; under the arm-pit, 
and then spirally around the chest. (Fig. 141.) 




196 



FRACTURES OF THE BONES 



The surgeon then flexes the forearm on the arm, 
and bringing the latter down along the pad, presses 
its lower extremity forcibly against the side of the 
chest. This, by forcing the shoulder outwards, draws 
the clavicle to its original length ; for the humerus 
being thus made a lever of the first kind, its upper 
end is drawn from the shoulder, in proportion as the 
lower end is forced against the thorax. He at the 
same time, directs its head upwards and backwards, 
and thus immediately reduces the fracture, an as- 
sistant holding it so until the next two bandages are 
applied. These, are intended to keep the fracture 

reduced. With this view, 
^i^- 142. place the commencement 

of the second roller, in the 
axilla of the sound side ; 
carry it across the breast ; 
over the upper part of the 
arm of the injured side, 
and obliquely round the 
back, to the axilla, whence 
it started, and continue 
these turns down the arm 
to the upper part of the 
forearm ; drawing them 
gently at first, and gradu- 
ally tightening them as 
they approach the elbow, so as to force it well in- 
wards. (Fig. 142.) 

The object of this roller is, to carry the shoulder 
and head of the humerus outwards, by pressing the 
elbow inwards. In order now to keep the shoulder 
upwards and backwards, the third roller is placed in 
the sound axilla, passed obliquely over the front of 
the chest to the fracture, where there should be a 
compress ; over this, and down the back of the arm to 
the elbow; thence obliquely upwards to the front of 
the sound axilla ; under this, obliquely upwards over 




OF THE HEAD AND TRUNK, 



197 




the back, over the fracture, down the front of the 
arm to the elbow, and 
thence obliquely to the Fig. 143. 

back; then to the sound 
axilla; under this to its 
front part, and over 
the chest and fractured 
bone, to run the same 
course, and end by- 
circulars of the chest, 
so as to fix the whole. 
These turns form two 
triangles, (Fig. 143) 
one of which is before 
the breast, the other 
on the back, and 
are the only difficult 
turns to recollect. 
But when we remember, that starting from the sound 
axilla, the bandage is to go over the fracture, down 
the arm to the elbow, and from the elbow always to the 
axilla, there will be no difficulty in its application. 

After this, it remains for us to support the fore- 
arm by a sling, and cover the whole apparatus by 
the piece of muslin before spoken of, in order to pre- 
vent the turns of the roller from slipping. 

The principles upon which this bandage acts, viz., 
by converting the humerus into a lever of the first 
kind, carrying its lower extremity forwards, inwards, 
and upwards, and thus pushing the shoulder back- 
wards, outwards, and upwards — renders it exceed- 
ingly well adapted to these fractures. The pad placed 
in the axilla serves as the fulcrum ; and one of the 
great advantages of the apparatus is, that it may be 
readily constructed. The apparatus is liable, however, 
to some objections; thus, for instance, the compression 
which it exerts about the chest, renders it ill adapted 
to females or patients of a delicate constitution ; it is 



198 



FRACTURES OF THE BONES 



also very heating in warm weather ; requires* to be 
taken off and re-applied at least every two or three 
days, from the circumstance of its becoming easily 
displaced by the movements of the patient, especially 
if it is a child ; whilst the pressure on the axillary 
nerves and blood-vessels, from the too great tightness 
of the second roller, often causes considerable pain 
and inconvenience. 



BOYER'S BANDAGE FOR THE SAME, 

Is composed of a wedge-shaped pad for the axilla ; 
a quilted belt of webbing or of linen, about five 
inches wide, to surround the trunk, and fasten by 
means of straps and buckles ; a circular band for the 
arm, of the same materials as the belt, made to lace in 
front. Four straps are attached, two on each side, 
near the uniting edges, and four buckles to corre- 
spond with these, are fastened upon the belt, two before 

and two behind the 
FiST' 144. arm. Then the pad 

being placed in the 
axilla, and its bands 
carried one before and 
the other behind the 
chest to the opposite 
shoulder, are tied: and 
the belt is then passed 
round the body, be- 
neath the pad, and a 
little above the bend 
of the elbow, in order 
to buckle posteriorly. 
Next, the circular band 
is laced upon the arm, 
and brought in to the 
trunk by means of the 
straps and buckles. While the elbow is thus fixed 
firmly to the side, the pad tends by its resistance to 




OF THE HEAD AND TRUNK. 



199 



push the superior part of the arm outwards, and the 
elbow may be moved either forwards or back- 
wards by merely tightening the anterior or posterior 
straps, so as to carry the shoulder in the opposite 
directions. 

This bandage, acting upon the same principles as 
that of Dessault, is preferable to the latter only from 
the circumstances of its not being liable to become 
displaced, and from its causing a more limited com- 
pression of the chest ; the compression being capable 
of being regulated by means of the straps and buckles 
which unite the ends of the belt, better than by the 
turns of the roller. 



MAYOR'S HANDKERCHIEF BANDAGE FOR THE SAME, 

Requires two large handkerchiefs, one folded in 
triangle, the other in a broad cravat ; a cushion for 
the axilla ; and a soft 
pad forthe opposite shoul- Fig. 145. 

der. After which, the 
cushion is to be placed 
in the axilla, and the 
arm brought against it 
with the forearm bent ; 
the doubled edge of the 
handkerchief, folded tri- 
angularly, is then made 
to envelope the elbow by 
foldingitssummitaround, 
while the angles support 
the hand ; the posterior 
angle being carried up 
under the axilla and be- 
hind the back to the op- 
posite shoulder, upon which a compress is previously 
placed, when the anterior one is brought up in front 
to meet the former and tie. 




200 FRACTURES OF THE BONES 

The second handkerchief, in cravat, is to confine the 
elbow and forearm more securely to the body, by 
being carried round the waist, and fastened upon the 
opposite side of the trunk. 

Mayor modifies this bandage in the following man- 
ner when intended for fracture of the acromion. After 
the first handkerchief or sling is applied, some com- 
presses should be placed upon the injured shoulder, 
and a few vertical turns of a roller passed round the 
shoulder and elbow, as in the third roller of Dessault ; 
after which, the second handkerchief is to be applied 
as above ; the cushion under the axilla should also 
be omitted, and a compress substituted, before ap- 
plying the first handkerchief, between the elbow and 
side. 

This mode of treating fracture of the clavicle an- 
swers very well as a provisional dressing, and better 
than the ordinary sling ; but where the other means 
can be obtained, a more perfect cure will certainly 
be accomplished by them. 

FOX'S APPARATUS, 

Is composed of a stuflfed collar ; a small pad ; an 
elbow-piece ; and a little sling for the forearm. 

The Collar, is made of a piece of four-inch muslin, 
sewed together on its sides, stuffed with cotton, and 
then joined at its ends. The Pad, is wedge-shaped, 
and like Dessault's, except that it is not so thick or 
so long ; being merely intended to fill up the space 
between the upper part of the arm and the side, and 
yet, leave a space between the elbow and the ribs, to 
which the former is brought by the action of the sling. 
Two tapes, attached to its thick end, fasten the pad to 
the collar. The Elbow-piece, or Sling, is made of 
strong muslin or brown holland, like half of the sleeve 
of a coat, and embracing the elbow, mounts half way 
up the arm, and descends to near the wrist. To its 



OF THE HEAD AND TRUNK. 



201 




upper and posterior ends, are attached two pieces of 
broad tape, long enough to reach across the back to 
the collar ; and on its lower portion are two loops to 
receive a tape, for the front. Then place the collar on 
the sound shoulder;the 
pad in the injured ax- ^^^- 1^^- 

ilia, and fix it there 
by carrying its tapes, 
one in front of, the 
other behind the chest, 
to tie them on the col- 
lar. Flex the forearm ; 
place the elbow-piece 
on it and the arm, and 
bring the arm against 
the pad by the action 
of the sling. Fasten 
the posterior tape to 
the collar behind ; and run a tape or band through 
the loops near the wrist, so as to tie the forearm 
well up to the collar in front, as in Fig. 146. This 
will generally reduce the fracture completely, and is 
all that is required. 

Observations. — Of all the means recommended 
for the treatment of fracture of the clavicle, none are 
more simple, or fulfil better the indications, than this 
of Dr. George Fox, of Philadelphia. Made in a few 
minutes of materials nearly always at hand ; reducing 
the fracture, yet leaving it open to inspection ; light 
and easy of application ; producing no constriction 
of the chest, or pressure on the mammae, or on the ax- 
illary vessels or nerves, it offers advantages that no 
other means possess ; and Dr. Fox, by its introduc- 
tion into practice, has caused the perfect cure of very 
many cases, and saved the patients much unneces- 
sary suffering and inconvenience. In the Pennsyl- 
vania Hospital, it is the only means employed for the 
treatment of this injury, and repeated testimony has 



202 FRACTURES OF THE BONES 

been given of its ability to produce perfect cures ; it 
being a rare thing for a simple case of this fracture 
to go out of the house with any deformity, save that 
which time cures, viz. , the deposition of the provisional 
callus. From 1829 up to the year 1838, — a period of 
nine years, — seventy-five cases of fractured clavicle 
were treated in the house ; of which sixty-three were 
discharged cured, and twelve left the house while 
under treatment ; the apparatus allowing of their 
walking about as usual.* In the subsequent years, a 
large number of cases have also been treated with 
such success, that no one who has employed it, ever 
resorts to any other means of treatment, except in 
special cases, where an additional bandage, as a pos- 
terior 8, &c., may be added ; but generally when 
there is any derangement of the fracture, it is only 
necessary to tighten the anterior or posterior tapes of 
the sling, in order to remedy it. The effect produced 
on the bone by this apparatus, is well shown in the 
testimony of Dr. Norris, one of the surgeons of the 
hospital, who, in his notes to Liston's Surgery, says, 
" he was enabled to treat with entire success, a forward 
dislocation of the sternal end of the clavicle, after 
Dessault's bandage had been several times well ap- 
plied, but without success." The difficulty of retain- 
ing the bone in its position in this injury, being so 
much more difficult than in cases of fracture, speaks 
highly in favour of the powers of the apparatus. 

FRACTURES OF THE SCAPULA, 

Are generally accompanied by so much inflamma- 
tion from the contusion, as to render the removal 
of this an object of greater importance, than the treat- 
ment of the fracture itself. Warm fomentations, by 
means of bags of chamomile flowers, or flannels wrung 

♦ Wallace's Statistics of Fracture: Med. Examiner for 1838. 



OF THE HEAD AND TRUNK. 



203 



out of hot water, leeches, &c., must therefore be first 
employed ; after which we may employ the pad, and 
first and second roller of Dessault, Fox's Apparatus, 
or the bandage of Velpeau, which, as the author says, 
is applicable to acromio-clavicular luxations; to frac- 
tures of the acromion or other points of the scapula ; 
to fractures of the neck of the humerus, as well as to 
fractures of the clavicle. But from numerous oppor- 
tunities that I have had, of witnessing the result of its 
application to the latter injury, in his own wards, I 
think it is not as perfect in its cures, as the means 
before referred to. To the other cases it is well 
adapted, and is applied as follows : 

VELPEAU'S BANDAGE. 

Make the patient embrace the sound shoulder with 
the hand of the injured side, placing a compress or 
piece of muslin between the side of the chest and the 
injured arm, in order to prevent excoriation of the 
two surfaces, from contact and perspiration. Then 
place the initial extremity of a roller ten yards long, 
and two and a-half 
inches wide, under, or 
behind the axilla of the 
sound side, and con 
duct it over the back 
over the injured clavi 
cle ; down on the fron 
and outside of the arm ; 
under the outside of the 
elbow; up and over the 
chest to the sound axilla. 
Make two similar turns, 
and on again reach- 
ing the axilla, pass cir- 
cularly around the chest 
to the same axilla; then 
make a turn over the 




204 FRACTURES OF THE BONES, ETC. 

clavicle and arm ; then a circular, and so on until it 
reaches the upper part of the forearm, as seen in Fig. 
147. By means of this bandage, especially when 
wet with starch or dextrine, the arm is supported in a 
firm cap, which will last for weeks without changing; 
but where these articles are not used, several pins 
must be placed at the different turns in order to se- 
cure them. It will require but the application of this 
bandage, to prove its power in the accident referred 
to, and dislocations of the humeral extremity of the 
clavicle, are so difficult to keep reduced, that the 
bandage becomes a very valuable addition to our 
other means of treatment. 



FRACTURES OF UPPER EXTREMITY. 205 

CHAPTER III. 
OF FRACTURES OF THE UPPER EXTREMITY. 

FRACTURE OF THE NECK OF THE HUMERUS, 

Is generally treated by Boyer^s Bandage, which is 
composed of two rollers, two and a-half inches wide ; 
— three strong pasteboard splints, between two and 
three inches broad, and the length of the arm ; — a 
pad, four inches thick at one end, terminating at the 
other in a narrow point, and long enough to reach 
from the axilla to the elbow ; so as to serve as an 
inside splint, and fulcrum for the reduction of the 
fracture ; the thick end being in the axilla, if the lower 
fragment is drawn inwards, and the reverse, if the 
upper one is thus drawn ; — lastly, a sling to support 
the forearm. 

Then, the fracture being reduced, and maintained 
by assistants, the surgeon fixes the initial extremity 
of one of the rollers, at the upper part of the wrist by 
two or three circulars, and winds it round and up the 
arm, as in the Spiral of the Upper Extremity, until 
he arrives at the upper part of the limb, where several 
turns must be made around the fracture so as to bind 
it firmly, and overcome the action of the muscles. 
From hence he carries the head of the roller twice 
round the opposite axilla, and confides it to one of 
the assistants, who retains it upon the top of the 
shoulder of the injured side. The first splint being 
then placed in front, reaches from the bend of the arm, as 
high as the acromion; the second, on the outside, from 
the external condyle to the same height ; and the third, 
from the olecranon behind, to the margin of the axilla. 
These being given to another assistant to hold, 
the surgeon then takes the same roller, or a new 



206 OF FRACTURES OF THE 

one, and fixes the splints to the arm, by moderately 
tight spiral turns, and while the assistants still keep 
up the extension, he places the cushion between the 
arm and trunk, taking care to put that end upwards, 
which the deformity calls for : lastly, bringing the 
arm against the trunk, he confines it there, by means 
of the second roller, or turns of the same one applied 
horizontally around the body. Each turn of this 
roller should be tighter below and slack above, if 
the lower fragment be displaced inwards ; but if it 
is drawn outwards, they should be slack below and 
tight above, in order to act on the extremities of the 
lever, formed by the humerus. The forearm is then 
to be sustained by a sling, which should not go under 
the elbow, lest it cause shortening of the arm ; but 
should merely support the hand. 

FRACTURE OF THE BODY OF THE HUMERUS, 

Is also most frequently treated by Boyer's Bandage. 
This requires a single-headed roller, eight or nine 
yards long, and two and a-half inches wide ; four 
splints, not quite so long as the arm, nor so broad as 
to touch each other when applied ; and some charpie 
or cotton to pad them. 

The surgeon then commences by applying a spiral 
of the limb, fixing its initial end by a few circular 
turns above the wrist, and proceeding as in the spiral 
bandage of the upper extremity before referred to. 
He continues the turns of the roller from the elbow 
to the upper part of the limb, applying it firmly over 
the seat of the fracture, and filling up the depression 
about the insertion of the deltoid muscle, in order to 
make uniform pressure. He next places the splints, 
well padded, along the arm, on its inside, front, back, 
and outside, and resuming the roller, covers them in 
by spiral turns, and fastens the bandage by pins, 
until the whole is rendered firm ; when the forearm 
should be fastened across the chest. 



UPPER EXTREMITY. 207 

But if in these fractures this last point be omitted, 
and the arm and forearm are not well secured to the body ; 
or if the patient becomes restless ; more or less motion 
will be produced at the elbow-joint, which will de- 
range the lower fragment, and by the slipping of the 
turns of the spiral bandage on the forearm, necessitate 
its almost daily re-application. 

THE PLAN OF THE PENNSYLVANIA HOSPITAL, 

Is, therefore, to dress the case as follows: — After 
applying a roller from the fingers to the shoulder 
— place a padded, angular splint, similar to Phy- 
sick's splint for fracture of the condyle, on the in- 
side of the arm, extending from the axilla to the 
ends of the fingers. Place, also, three splints of the 
length of the humerus, on the front, back, and out- 
side of the arm, and bind them all to the limb by the 
ordinary spiral bandage ; commencing at the wrist 
and extending to the shoulder. During the treat- 
ment, the angle of the inside splint should be occa- 
sionally altered, and passive motion made, to guard 
against stiffness of the elbow-joint. 

The advantages of this method are, that by pre- 
venting motion at the elbow-joint, it keeps the lower 
fragment perfectly at rest, and the arm in a more con- 
venient position to the patient. It must, however, 
be recollected that this, like the previous dressing, 
is only applicable to fractures of the humerus below 
the insertion of the pectoralis major muscle. 

FRACTURE OF THE CONDYLE. 
PHYSICK'S METHOD. 

The position of the condyles to the elbow-joint, 
renders the treatment of this fracture a matter of 
great importance ; as, without proper attention, the 
inflammation may extend to the joint, produce anchy- 
losis, and deprive the patient of the use of the limb. 
When the fracture is simple, the best method of treat- 
ing it is that proposed by the late Dr. Physick. 




208 OF FRACTURES OF THE 

The forearm being flexed on the arm so as to relax 
the flexor and extensor muscles, apply a bandage 
from the fingers up to the shoulder by spiral reversed 
turns ; making a figure of 8 around the elbow. Then 
prepare two angular splints like Fig. 148, of the same 
angle as that which the forearm takes when flexed, 
and covering them well with cotton, place one on 

the inside, and the other 
^^i' 148. on the outside of the arm, 

from the shoulder down 
to the fingers, and confine 

__.,^ them by another spiral 

illllllllllllllllllllliillilllllllllllllllllllllllllllllillliliy bandage, exactly like that 

of the Upper Extremity. 
The forearm being now brought across the chest, 
should be placed in a sling, with the palm of the 
hand next to the front of the chest, and the thumb 
pointing upwards to the chin. In pursuing this 
treatment, attention must be paid to the state of 
the internal condyle, which, unless the splint is well 
padded, is very apt to ulcerate from the pressure. 
The angle, also, of the splint should be changed every 
third day during the treatment, after the first ten 
days, in order to prevent anything like anchylosis. 

If the fracture is complicated with contusion of the 
jomt, or if it should be compound, a better plan will 
be found in the use of a carved angular splint like 
Fig. 149, in which the arm may lie, loosely confined 

by a few strips of Scul- 
Fig' 149. tet's bandage ; while 

leeches, cold washes, 
&c., may be applied to 
the part, in order to 
combat the inflamma- 
tion. Or it may be simply 
flexed and laid on a 
pillow, till the swelling isreduced ; and then be treated 
as a simple fracture. 




UPPER EXTREMITY. 209 

In order to make this carved splint, or in order 
to make a carved splint for any of the limbs, pur- 
sue the following plan. Lay the limb on a piece 
of stiff paper, or soft wood, and mark an outline 
of its shape with a pencil, tracing accurately its 
angle, its prominences, &c., by running the pencil 
over its surface. Then seeing that the w^ood is thick 
enough to allow the limb to sink into it, to the depth 
required, scoop it out in the lines of the pencil, 
and shave off the outside, with a spoke-shaver or 
gouge, so as to reduce its thickness and make it cor- 
respond externally and internally with the roundness 
of the limb. A piece of linen or muslin being then 
pasted over the outside to prevent its splitting from 
moisture, and the inside covered in the same way 
with soft buckskin to prevent the chafing of the skin, 
it is ready for use. 

These splints are of great utility in the treatment 
of all injuries in the neighbourhood of joints, and so 
simple, that any one of the least mechanical ingenuity 
can make one that will answer the purpose very well, 
though the aid of a professed carver is desirable, when 
a very light and perfect splint is required. Paste- 
board, tin, &c., are frequently used for the same 
purpose, but do not form as neat a dressing, and are 
also liable to be bent out of shape. 

FRACTURES OP THE FORE-ARM. 

Fracture of one or both bones of the forearm are 
dressed exactly in the same way, with the exception 
of fractures of the lower end of the radius, and of the 
olecranon, or upper extremity of the ulna. The frac- 
ture being reduced by means of the extension at the 
wrist, and counter-extension at the elbow, the muscles 
should be well kneaded, in order to preserve the 
interosseous space. Then, according to the plan of 
the Pennsylvania Hospital, take two straight splints, 
long enough to extend from the bend of the arm, to be- 
14 



210 OF FRACTURES OF THE 

yond the fingers ; half an inch wider than the forearm, 
and well padded with cotton, which should be con- 
fined to them by a roller, and thickest on their middle, 
so as to act as a pyramidal compress on the interos- 
seous space. Then apply one of these splints on the 
front, the other on the back of the forearm, whilst it 
is in a state between supination and pronation, or, 
in other words, while the bones are perfectly parallel, 
and confine them there by a roller, only moderately 
tight at first, so as to guard against swelling. After 
the lapse of a week, draw the roller more firmly, so 
as to cause the padding of the splints to act on the 
interosseous space ; but be careful that it is not too 
tight, and continue this dressing till the case is cured. 
The case of amputation of the arm, performed in 
this Hospital, consequent upon the mal-application of 
the roller in a simple fracture of the radius, as before 
mentioned, should caution us against the use of too 
much traction in the application of the bandage, espe- 
cially, immediately after the occurrence of the injury. 

FRACTURE OF THE LOWER END OF THE RADIUS. 
BARTON'S METHOD. 

This fracture, often similates a sub-dislocation of 
the wrist, owing to the falling of the hand, as seen 
in the cut, and so frequent is it, that eight out of ten 

Fig. 150. 




supposed sub-dislocations of the wrist will probably 
be found to be fractures of this kind. For the best 
treatment of it, we are indebted to Dr. J. Rhea Bar- 
ton. His apparatus consists of two compresses, about 



UPPER EXTREMITY. 211 

three inches by two, or else two and a-half inches 
square, graduated from one end ; — two splints pre- 
pared as in fracture of both bones of the forearm ; 
and a two and a-half inch roller. Then, place one 
of the compresses on the front of the wrist, with its 
thick end downwards, and about one- eighth of an 
inch above the articulating end of the radius ; place 
the other on the back of the wrist, with its thick end 
upwards, so that it may be on a line with the upper 
row of the bones of the carpus, or on a line with the 
end of the first compress, so that one may begin, where 
the other ends, though on opposite sides of the wrist. 
Fasten these, by a few turns of a roller loosely ap- 
plied ; then place the two splints in their position, one 
on the front, the other on the back of the arm, ex- 
tending from beyond the fingers up to the elbow, and 
bind them there by the spiral bandage, as in fracture 
of both bones. After a few days, the tightness of the 
bandage may be increased, and motion made to a. 
slight extent m the joint in order to prevent anchylosis,. 
If instead of the bulging on the back of the hand, as, 
generally seen, it should be on its front, we have 
only to change the relative position of the compresses, 
and then pursue the same plan. 

FRACTURE OF THE METAXARPAL BONES, 

Is generally caused by heavy weights falling on them, 
and producing such a degree of contusion as to re- 
quire our closest attention to combat the inflammation. 
In this case, we should employ a splint carved out 
to fit the forearm and hand, placing a small mass of 
cotton under the palm, so as to preserve its concave 
character, and then allow the limb to be open in 
the splint, till by leeches, cold washes, &c., we have 
reduced the inflammation. If, however, the fracture 
is produced by a fall on the hand, we shall most fre« 
quently find it in the bone of the little finger, this 
being one extremity of the arch, formed by the meta- 



212 OF FRACTURES OF THE 

carpal bones, and the one most exposed to the shock 
in falling. To dress this accident, place a mass of cotton 
in the hollow of the hand, as before done, and ban- 
dage the limb to a splint with a broad palmette or 
hand-piece ; taking care that it extends from the ends 
of the fingers, up to near the elbow, in order to pre- 
vent the action of the carpal muscles. 

FRACTURES OF THE PHALANGES, 

If simple, should be first covered in with a spiral 
bandage of the finger, and then kept in their position 
by means of four small splints of binder's board ; 
those on the front and back of the finger, reaching 
from its extremity, as high as the wrist, but the two 
lateral ones, extending only the length of the finger. 
All these should be padded with cotton, and confined 
by a second spiral of the fingers, the roller in each 
case being under an inch in width. Attention should 
also be especially given to the state of the joints in 
these fractures, and passive motion be early made ; 
a stiff finger being a serious inconvenience. 

FRACTURE OF THE OLECRANON. 

In this injury the upper fragment is drawn up by 
the action of the triceps muscle. All the means of 
treatment have therefore the same object, viz., the 
bringing it down, or the placing of the two fragments 
as closely in contact as possible, in order to diminish 
the amount of ligamentous union. When from ex- 
coriation, or other accidents, one method is not avail- 
able, another may be substituted, as all have some 
points which recommend them to particular cases. 

SIR ASTLEY COOPER'S APPARATUS, 

Is composed of two strips of muslin, or tape, each 
about half a yard long ; — two short rollers, and 
another roller of the ordinary length, and a light 



UPPER EXTREMITY. 



213 



Fig. Ibl. 



splint made sufficiently long to extend from the 
margin of the axilla about half way- 
down the forearm. Then, the pa- 
tient's forearm being extended, and 
the upper fragment pressed down 
until it touches the body of the 
ulna, a strip of linen should be ap- 
plied above and below the joint, 
and one of the short rollers passed 
round the limb above, and the other 
below the olecranon, to secure them, 
as at b h. The extremities of each 
tape being reflected and tied together, 
as at a, draw the rollers nearer to 
each other, and place the upper 
fragment of the olecranon in the 
closest apposition possible, to the 
lower. Lastly, the split splint, c, 
well padded, is applied along the 
front of the arm, and secured by a 
bandage, d d, which is to be fre- 
quently wetted with an evaporating 
lotion ; care being taken in setting the fracture, that 
the intesjuments are not pinched between the frag- 
ments, as this would prevent their union. 

DESSAULT'S, APPARATUS FOR THE SAME, 

Consists of a strong pasteboard splint, long enough 
to cover a part of the arm and forearm, and shaped 
so as to accommodate itself to the bend of the elbow, 
when the arm is in a demiflexed position ; — a roller 
five or six yards long, and two and a-half inches 
wide, — and some compresses or lint. Then whilst the 
limb is maintained by two assistants in demiflexion, 
the surgeon proceeds to cover in the hand and fore- 
arm with the roller ; as he approaches the elbow an 
assistant draws the skin, which is here usually wrin- 
kled, gently upward, to prevent it being caught be- 




214 OF FRACTURES OF THE 

tween the fragments, and the surgeon pushes down 
the fractured extremity of the olecranon, in order to 
place it in contact with the body of the ulna. He 
now confines it in this situation, by means of a few 
turns of the roller, carried round the joint in form of 
a figure of 8, as in the bandage for phlebotomy ; and 
the elbow being at length covered, carries the roller 
spirally as far as the axilla, in order to compress the 
triceps, and prevent its action on the upper fragment. 
The carved splint being then well padded with the 
lint or compresses, is applied along the front of the 
arm and forearm, and fixed by a succession of oblique 
turns of the remainder of the roller, carried down to 
the wrist. 

THE HOSPITAL APPARATUS. 

At the Pennsylvania Hospital, the apparatus con- 
sists of two, two and a-half inch rollers ; a splint to 
extend from the middle of the arm to below the mid- 
dle of the forearm, and of the width of the arm ; and 
of some cotton or tow, to fill up the hollow at the bend 
of the arm. 

The forearm being then extended on the arm, and 
the upper fragment brought down, and held by an 
assistant, apply the ordinary Spiral of the Upper Ex- 
tremity from the fingers up to the shoulder, making 
figure of 8 turns around the elbow so as to keep the 
fragments in apposition, and applying it firmly around 
the arm, to prevent the action of the muscle. Then 
apply the tow to the bend of the arm, and bind the 
padded splint on its front by a second spiral bandage. 
After ten or twelve days, a slight degree of flexion 
is made at the elbow and gradually increased to prevent 
stiffness, the fracture being maintained in its position 
by the fingers of the surgeon during this movement. 

BOYER'S METHOD. 

According to this surgeon, the indications are to 



UPPER EXTREMITY. 215 

keep the fragments as closely as possible in apposi- 
tion, without uselessly fatiguing the muscles by com- 
plete and constant extension of the forearm ; and also 
by rest, to favour the formation of the ligamentous 
substance, without allowing the joint to become stiff. 
In order to do this, he advises that the forearm 
should be slightly flexed on the arm, so as to make 
an obtuse angle with it, and then an ordinary spiral 
bandage applied from the fingers to the elbow. The 
fragment being now drawn down, a narrow strip, or 
long compress, is placed behind it, and fastened by 
crossing its ends in a figure of 8 around the forearm ; 
after which, the bandage is continued over it in the 
form of several figures of 8, and then carried by spiral 
turns up to the shoulder, so as to compress the triceps. 
To guard against anchylosis, motion should be made 
at the joint about the twentieth day, and at the forty- 
fifth, the cure is usually complete ; the union being then 
quite firm, and, as he says, as solid as it ever will be. 
Should there be much swelling or pain, he advises that 
the bandage should not be applied, or the reduction of 
the fracture attempted, but the limb be simply placed 
on a pillow, and the inflammation treated by local 
means. If it does not disappear by the twentieth 
day, the case may be left to nature ; a number of in- 
stances, which he reports, having shown, that even 
when thus left, it will gain as much strength and 
freedom of movement, as when confined more closely. 

THE CARPO-OLECRANIEN HANDKERCHIEF OF M. MAYOR, 

Has been already mentioned. It will answer very 
well, in many cases, as a provisional dressing. 

THE UNITING BANDAGE OF GERDY, 

For transverse wounds, and for fractured patella, is 
also applicable here, but as its use is more frequent 
in the patella than elsewhere, we shall reserve its 
description until we treat of that accident. 



216 OF FRACTURES OF, ETC. 

When the fracture of.the olecranon is compound, 
or complicated with severe contusion, the effect of 
the inflammation on the joint renders its treatment the 
most important indication, and it will be better, there- 
fore, to place the limb in the carved angular splint 
before spoken of, and confine it by a few strips of 
Scultet's bandage, employing leeches, cold washes, 
&c., as in compound fractures of the condyles of the 
humerus, than to use either of the dressings just men- 
tioned. 

FRACTURE OF THE CORONOID PROCESS OF THE ULNA, 

Resembles a dislocation of the bones of the forearm 
backwards. By pulling the forearm, and at the same 
time flexing it, the dislocation is easily reduced, but 
returns again immediately on the force being re- 
moved. Jn order to prevent this, flex the forearm 
on the arm, as in fracture of the condyles, and bind- 
ing a padded angular splint along its inside, keep it 
flexed for several weeks ; the action of the brachialis 
internus, which is liable to reproductive deformity 
being prevented by the turns at the elbow. This 
accident is, however, a very rare one. Dr. Physick 
having seen but one case which he thus treated, 
and Sir A. Cooper, and Mr. Liston having, also, seen 
but one or two instances of it. 



OF FRACTURES, ETC. 217 

CHAPTER IV. 

OF FRACTURES OF THE LOWER EXTREMITY. 

In few cases requiring surgical attention, has there 
been as many proposed plans of treatment, as in the 
fractures of which we are about to treat. Almost 
every year, and from every section of the country, we 
have accounts of some new modification, or some de- 
cided improvement in their apparatus, which, in the 
opinion of the in^^entor, and from the decided testi- 
mony of one or two^p«^fectly cured cases, must sup- 
plant everything heretofore known ; when, perhaps, 
the great and improved modification, consists only in 
the substitution of narrow strips for broad bands, or 
in the difference of a buckle, or the peculiar shape of 
a hinge. To refer, then, to all these, would be as 
useless as uninteresting ; and we shall, therefore, pre- 
sent only the more original plans, premising a few 
remarks on the duties of the surgeon in the prepara- 
tion of the means requisite for their treatment gene- 
rally. 

When called to a fracture, or even a supposed frac- 
ture of the lower extremity, our first duty should be 
to consider in what way the patient may be most 
readily moved, and prepared for his dressing, and 
then how that dressing is to be obtained. 

First. How are we to prepare for the removal and 
dressing of the patient '^ 

In cases of this kind, a shutter, door, frame, or 
settee, is usually selected, on which the patient is 
placed encumbered with his ordinary dress, and as we 
know that for the proper treatment of his case, per- 
fect repose of the limb is absolutely essential, our 
thoughts, naturally turn, to his place of rest during the 



218 OF FRACTURES OF THE 

treatment, and to the selection of the bedstead and bed. 
The first will be readily found in the ordinary bed- 
stead, provided it is low and narrow ; with a low head- 
board ; without afoot-board ; and made into what is cal- 
led a Fracture Bed. This is prepared by first draw- 
ing the sacking-bottom as tightly and drum-like as 
possible ; or if slats can be had, by placing them in 
their position, and cutting in the centre of either, a 
hole large enough to admit a pot ; nailing on the 
underside of the bedstead, at a distance to correspond 
with the width of the pot, two strips, grooved or 
ploughed like the strips in which an ordinary coun- 
ter-draw runs, so that they may receive the rim of 
the pot, and allow of its sliding in and out under the 
patient. If a number of these bedsteads are required, 
as in a hospital, it will be found most useful and 
cleanly, to have them made of iron, as they are more 
readily preserved from bugs, &c. 

After the bedstead, we should prepare a hair, or 
firm and even mattress to fit it, by cutting out a piece 
to correspond with the hole in the frame, and sewing 
the cut edges of the ticking together; thestuffingbeing 
so arranged that the edges of the hole may not be 
hard or knotted. We then place over this, a sheet 
with a similar hole in its centre, and arrange on it, 
the preliminary portions of the apparatus to be used ; 
after which we may turn our attention to the patient. 
Having carefully removed his clothes, &c., we should 
prepare to remove him to the bed. To do this pro- 
perly, see that the open side of the settee corresponds 
with the side of the bed, and the head of the patient 
with its head, especially if the room is narrow ; other- 
wise we may be compelled to carry the settee out of the 
chamber, and perhaps down stairs, in order to turn it, as 
we haveoccasionallyseen done, at the expense of much 
unnecessary pain and trouble. We next procure three 
assistants, and having informed them of their duties, 
place one at each shoulder of the patient, so as to 



LOWER EXTREMITY. 219 

face each other, and the third at the limb on the 
sound side, while the surgeon himself takes charge of 
the injured limb, and directs the assistants at the 
shoulders to pass one of their arms under the pa- 
tient's neck and shoulders. Then let them slide the 
other hand under his buttock, so as to clasp each 
other's fingers in what is known as the sailor's grip, 
or, in other words, grasp hands, by making the pal- 
mar side of their fingers touch. 

The third assistant, holding the sound limb, the 
surgeon places one hand under the seat of fracture, 
the other under the calf, if in the femur, and at the 
word to move, directs the assistants to lift and carry 
the patient down to the foot of the settee, so as to get 
free from it, and then passing, one on each side of 
the narrow bedstead, to place their burthen so that 
the lower part of the buttocks may correspond with 
the upper edge of the hole in the mattress, when the 
dressings may be readily applied. If instead of a 
fractured thigh, it is a fractured leg, the arrangements 
should be the same, except that the surgeon should 
grasp the leg with both hands, one being at the knee, 
and the other just below the seat of the fracture, or 
at the ankle. 

These directions, though minute, are absolutely 
necessary to prevent the suffering of the patient, and 
the awkwardness produced by want of attenton to 
them ; assistants or inconsiderate surgeons being very 
apt so to place themselves, that on moving the pa- 
tient, they come directly between the bed and the 
patient, thus necessitating their lying down, or crawl- 
ing across the bed in order to get out of the way. 

Where it is found difficult to prepare the bed as 
thus directed, a very excellent and simple substitute 
will be found in a frame made of sacking or strong 
cloth, nailed on two narrow strips several inches 
longer than the bed, and joined by two transverse 
ones, a little wider than the bed. 



220 



OF FRACTURES OF, ETC. 



Fi^: 152. 



This being placed on an ordinary 
firm mattress, and a sheet, with a 
central hole placed over it, the pa- 
tient will lie as on an ordinary bed 
till he requires a stool, when assist- 
ants at the head and foot of the bed, 
may raise the frame like an ordinary 
hand-barrow, and by placing its 
ends (Fig. 152)onfour heavy chairs, 
readily air the bed, or even remove 
it, and of course can aJso easily pass 
a pan under the frame to receive the 
discharges. 

Having now completed these ar- 
rangements, we should proceed to 
the 

Preparation and application of 
the apparatus. 

This will, of course, depend on 
the injury. In fracture of the femur 
below the neck, the extended posi- 
tion, as recommended by the French 
surgeons, is almost the only one em- 
ployed, as far as we know in the United States ; the 
apparatus of Dessault, as modified by Drs. Phy sick and 
Hutchinson ; the apparatus of Boyer, modified by 
Hartshorne; or that of Hagerdon, modified by Prof. 
Gibson, being almost the only ones employed, though 
we occasionally see the plan of Amesbury, and of Prof. 
Nathan R. Smith, in use, in special cases. 




FRACTURES OF THE FEMUR. 



221 



CHAPTER V. 



OF FRACTURES OF THE FEMUR. 



IN FRACTURES OF THE NECK OF THE FEMUR, 

Within the capsule, especially in old persons, as the 
union will generally be ligamentous, it is sufficient 
to bend the limb on itself, on a double-inclined plane, 

Fig. 153. 




such as that of Sir Charles Bell, (Fig. 153,) Ames- 
bury, &c., or to use the method of Dupuytren, in 
which a double-inclined plane is formed by cushions 
of different sizes, covered by a common sheet. 

DUPUYTREN'S PLANE, 

Is made by three or four cushions, decreasing in size 
from below upwards, being placed under the ham ; 
and the rest so disposed as to form a double-inclined 
plane. On the upper portion of this, the thigh is 



222 FRACTURES OF THE FEMUR. 

made to repose, while the leg, in a state of flexion, 
rests upon the lower ; the limb being maintained in 
this position by means of a sheet folded like a cravat, 
the central part of which embraces the foot, while 
the extremities are attached to the sides of the bed. 

Simple, however, as this is, the plan frequently 
pursued by surgeons in this country is more so, and 
answers equally as well. This consists in doubling 
an ordinary pillow on itself, and placing it under the 
ham and leg ; thus making a plane of the simplest 
kind, and giving, by the addition of a band to fix 
the foot, all that is requisite for the treatment of this 
injury. 

But in fractures of the shaft of the bone, the ex- 
tended position being, as before stated, preferable to 
the bent one, the treatment is very different. Here, 
owing to the shortening produced by the muscles, 
we must employ some means of making extension 
and counter-extension, as it is usually termed ; though 
in reality, the means of extension should always be 
the hands of the surgeon, and the bands be used only 
to preserve the extension when he has made it. 

To keep up this extension, various bands have 
been employed; but it matters little of what they 
are made, provided they are flexible, soft, and porous, 
especially the latter, so as not to unduly promote the 
insensible perspiration, and thus favour excoriation. 
But as these qualities are seldom found united, most 
of the means of preserving extension are made of two 
substances, the best of which are brown holland linen, 
and buckskin. These may be employed either as in 
the band of Drs. Coates and others, or in the gaiter of 
Dr. Physick, which is a modification of that of Petit. 

DR. COATE'S BAND FOR PRESERVING EXTENSION, 

Is made of a piece of brown holland, slightly 
biassed, but leaving the central threads continuous 
throughout, from fifteen to eighteen inches long, if 



FRACTURES OF THE FEMUR. 223 

designed for an adult; two inches wide in the middle 
and narrowing on each side, rapidly at first, then 
slowly, towards the extremities, which are an inch in 
width. This should be lined, throughout nearly its 

Fig: 154. 




whole length with thick buckskin, a very little wider 
than the linen, the latter being simply basted to the 
former, by stitches which dip but half way through 
the skin, in order that they may not produce irritation. 
Two pieces of tape, or webbing, each an inch wide, are 
then sewed securely to the ends of this band, so as to 
make it long enough to go over the lower end of the 
splint to which it is to be fastened. In applying this, 
place the centre of it over the tendo-Achillis, and 
bring the ends round above the malleoli, to the front 
of the ankle ; cross them on the top of the instep, and 
carrying them, down, knot them beneath the instep a 
short distance from the sole of the foot; when the 
tapes may be carried over the end of the splint, and 
tied. 

Where this band cannot be readily obtained, a 
common silk or Madras handkerchief, folded into a 
similar shape and applied like this band, answers 
quite as well. But in some cases, owing to the irri- 
tability of the patient, and the extension being made 
by the band, instead of by the hands of the surgeon, 
or owing to a want of attention to the smoothness of 
the band, or extreme tenderness in the skin of the 
patient, excoriations will happen. It is desirable, 
therefore, to be able, by changing the means of pre- 
serving extension, to bring the pressure to bear on 
different points, and we may then resort to 




224 FRACTURES OF THE FEMUR. 

PHYSICK'S GAITER. 

This is made of buckskin and kid, of cloth and buck- 
skin, or hollands and buckskin; but in either case, the 
buckskin should go next to the skin, as it is the softest, 
most porous, and flexible of all these 
Fiff. 155. substances. Cut out of either of these 

substances, two pieces of the shape of 
the figure, and make it eleven or 
twelve inches long at its greatest 
length, and eight inches at its least, 
for an adult, and about four inches in 
its other diameter. Work eye-let 
holes in the ends, to receive the cord 
w^hich laces it to the ankle, and sew 
a piece of buckskin on the inside of one end, so that 
it may come under the lacing when the gaiter is 
applied, and thus prevent the cord from pressing on 
the skin. Lastly, sew on two broad tapes or bands, of 
about three-fourths of a yard long, in order to pass to 
the end of the splint. 

In applying it, place a layer of carded cotton on 
the surface which is to be next the skin, and lace the 
gaiter smoothly round the ankle, from an inch above 
the malleoli, down on to the front of the instep. 
If the use of this causes pain, we should at once 
look to it, and if a slight change in its arrangement 
does not relieve it, rub the heel with whiskey or some 
slightly stimulating liniment. But should it produce 
excoriation, we must then resort to some other band, 
such as the Handkerchief of Dr. Barton, (Fig. 128) 
before treated of, and with these means of preserving 
extension, we shall probably have all that is neces- 
sary. 

Let us now look to the means of counteracting 
them, or the means of preserving counter extension. 
The padded band of Dessault, or Boyer, the bandage 
doubled several times on its length, or the use of a 
thick cravat, may all be objected to, as frequently 



FRACTURES OF THE FEMUR. 225 

causing excoriation of the part, and we shall there- 
fore, confine ourselves to the consideration of Coatees 
Perineal Band, which is decidedly the most perfect 
means that we know. 

COATE'S PERINEAL BAND, 

Is made of a piece of brown holland, long enough 
to go round the perineum, in the line of the groin, 
and reach above the crista ilii both before and behind. 
For an adult, it should be three or four inches wide. 
Double this in its width, and sew the edges firmly 
together, leaving one end open and closing the other; 
then turn it inside out like a bag, and pour in bran 
or chaff, sufficient to fill it lightly; then quilt one-third 
of the closed extremity so as to flatten it to the thick- 
ness of half an inch, and pour in a little more bran, 
stuffing it firmly, till the central third is quite round 
and firm ; after which, closing the open end, quilt the 

Fi^. 156. 



terminal one as before, attaching to each end, two 
broad tapes, three-fourths of a yard long. Next, 
take a piece of soft buckskin about three inches and 
a-half wide, and about half as long as the band ; double 
it, and stitch the edges together in order to form a tube 
with the ends open, so that when the band is about to 
be applied, it may be slipped over and cover that part 
of it, which is to press on the pubis, perineum, and 
tuberosity of the ischium ; then the seam being turned 
aside from these parts, secure it firmly to the band by a 
few stitches. When soiled, the buckskin may be easily 
changed, without requiring a new band. This piece 
is a great improvement to the ordinary band ; and, 



226 



FRACTURES OF THE FEMUR. 



according to the experience of the inventor, and from 
what we have ourselves seen, seldom or never pro- 
duces irritation. 

The Junct-Bags, or the stuffed cushions, are 
intended to prevent the pres- 
Fig-. 157. sure of the splints against the sides 

of the limb. These are made 
of muslin of the length of the 
limb ; or rather, long enough to ex- 
tend on its outside, from the pelvis 
to the external malleolus, and on 
its inside, from the perineum, to a 
point a little above the internal 
one. One end of this being sewed 
up, is then filled with bran or chaff 
till moderately full, and the open 
end being likewise closed, it forms 
a cushion of the width of the splint, 
and like Figure 157. 

In connection with this subject, 
and before describing what remains 
of the apparatus for fractures of the 
femur, let us glance at the remarks of 
Dr. Coates, in relation to the delay 
attending our preparations, as they 
contain points of much practical 
importance to the young surgeon. 
" There is scarcely ever," says he, 
" a necessity for rapid action in a 
case of fractured leg or thigh. But 
as it would be wrong to allow the 
patient to undergo the gradual 
shortening of the limb from con- 
tinual muscular action, while the surgeon rides off for 
his splints, or while he superintends their preparation 
in the shop of some carpenter who never saw what 
he is required to make : let him secure the limb by 
temporary means, and thus save his patient the exqui- 



FRACTURES OF THE FEMUR. 



227 



site pain of involuntary motions ; the irritation from 
the pressure of the fragments upon lacerated muscles ; 
and the increased force required to overcome their 
contraction. Place the patient, therefore, on the bed 
diagonally, and with extending and counter-extending 
bands,made of towels, handkerchiefs, &c., employ one 
head-post, and the opposite foot-post, for securing 
him. After which, the surgeon can proceed cooly and 
leisurely for his apparatus; certain that his patient 
suffers but little, and that scarce anything is lost by 
delay." 

THE SPLINT CLOTH, 

Is a piece of muslin, a yard and a-half long, one 
yard wide, and intended to keep the splints together, 
by being wrapt around them so as to form a kind of 
box for the limb. 

SCULTET'S BANDAGE, 

Which is also sometimes necessary, is made of strips of 
muslin about three inches wide, and of a length gra- 

Fig. 158. 




dually decreasing from the first strip. This, should 
be long enough to go once and a-third round the 



228 FRACTURES OF THE FEMUR. 

upper part of the limb, and each succeeding strip 
one inch shorter. To prepare and apply these, lay 
them down on a pillow or board, for subsequent 
convenience, so that the whole may readily be 
placed under the limb without being deranged ; 
placing each strip so that it shall cover only one-third 
of the preceding one. Then placing the limb on 
these obliquely in regard to their length, in order to 
favour their application, commence at the lowest 
part of the limb, and gradually ascend, drawing each 
strip moderately tight (Fig. 158). When it is neces- 
sary to change one or more of the strips, undo the 
bandage, and attaching the fresh band to the soiled 
one, draw the latter out, and thus place the fresh one 
in its place without deranging the limb. 

THE EIGHTEEN TAILED BANDAGE, 

Consists of a strip, three inches wide, and as long 
as the limb, to which are stitched crosswise, eighteen 
or more strips of an equal width, and sufficiently long 
to make a turn and a-half about the part, and cover 
in each other by about two-thirds ; each having a 
slight degree of obliquity, relative to the longitudinal 
piece. It was formerly applied like the bandage of 
Scultet, but has been supplanted by it, as its strips 
could not be changed, owing to their attachment to 
the centre piece. 

The Splints for fractured femur, differ in their 
form. Those of Dessault, consist of one for the outside 
of the limb, long enough to reach from the spine of 
the ilium, to four inches beyond the foot; and of 
another, extending from the perineum to the sole of 
the foot; both of them of the width of the limb. In 
the upper part of the outside one, are holes to receive 
the counter-extending band, and at its lower end one 
hole for the extending band. To these were added 
a splint in front of the thigh ; junct-bags; Scultet's 
bandage ; &c., as shown in Fig. 159. 



FRACTURES OF THE FEMUR. 229 

Being liable, to the objection of not preventing 

Fig. 159. 




lateral inclination of the pelvis, they are now but 
seldom used, except by the French surgeons. 

DR. PHYSICK'S SPLINTS, 

Are like these, except in the addition made to the 
length of the outer one, by which its end went nearly 
to the axilla ; thus making the counter-extension more 
in the line of the body, and preventing any inclination 
of the body to that side ; whilst the addition of a 
block, by Dr. Hutchinson, made the direction of the 
extending band also more in the line of the limb. 
To these were added the means of extension, 
counter-extension, Scultet's bandage, &c., before 
spoken of. With slight modifications, this is the 
apparatus now employed in the Pennsylvania Hos- 
pital, and, as the experience of the large number of 
cases there treated, proves it to be all that is requisite 
for simple fracture of the shaft of .the bone, we can 
safely recommend it, as the most simple of our means 
of treatment 

In its application, having arranged the patient, 
the bed, and the apparatus, as before shown, place 
the patient on the fracture-bed, with his buttocks 
corresponding to the hole, and put the counter-extend- 
ing band of Coates, in the groin of the injured side. 
Then roll the splints in the splint-cloth, on the 
floor, so that the splints may be of the proper distance 
apart, and give them to an assistant. The means of 



230 FRACTURES OF THE FEMUR. 

preserving extension being now placed on the foot, 
seize the limb above the ankle with both hands, and 
draw it gradually and steadily down (whilst an assist- 
ant, makes counter-extension by the perineal band) till 
the limb is nearly the length of the sound one, or till 
the spasmodic contraction of the muscles is overcome. 
This may require five or twenty minutes ; after which 
the splints and splint-cloth should be slid under and up 
the sides of the limb, by other assistants. The splints 
now lying flat on the bed, place the junct-bags on 
them ; and their stufl'ing being made to correspond 
with the prominences and depressions of the limb, 
press the outer splint to its side, against the junct- 
bag, and tie the counter-extending tapes through the 
holes at its upper part. Then the extending tapes 
being passed over the block, and one of them through 
the hole at the lower end of the outer splint, both are 
to be tied on the extremity of the splint, so as to secure 
the extension gained by the hands of the surgeon ; he 
keeping up this extension, till the bands are fixed and 
the outer splint in its place. The junct-bag being 
then arranged on the inner splint, and it turned 
against the side of the limb, pass three pieces of roller 
under the hollow of the knee and slide them up and 
down the limb,to their position, tieing them on the side 
of the splints. Looking now to see that the patient's 
body is perfectly straight in regard to his limbs, 
which may be told by seeing that the two anterior 
superior spinous processes are on the same level, 
measure from them to the internal malleolus of each 
limb, to see what is the difference in their lengths. 
Then placing a hoop, bent as in Figure 160, over the 
toes, to keep off the weight of the bed-clothes, the 
dressing is completed. If, after two or three days, 
or even ten days, we find there is still shortening of 
the limb, make the extension with the hands as before, 
and thus daily drawing on the limb, pull it down and 
tighten the bands, till it is of the same length, or as 



FRACTURES OF THE FEMUR. 231 

much so as possible ; a difference of an eighth of an 
inch, not being perceptible in the gait of the patient. 

Fig. 160. 




Generally the reduction is completed at the second 
visit ; but we caution the young surgeon against believ- 
ing that the fractured femur will in all cases, or in 
the majority of them, be perfectly of the length of the 
sound one. In favourable cases the difference will 
scarcely be perceptible ; but if attention is not paid 
to the position of the spinous processes, we may rea- 
dily deceive ourselves, and prove the limb as long, 
or even longer than the sound one ; a point of which 
some have boasted when speaking of the success of 
their treatment. If excoriation of the heel is likely to 
occur, the placing of a piece of kid spread with soap 
cerate on the part affected, or the substitution of some 
other means of preserving extension, so as to vary the 
point of pressure of the band, should be resorted to. 

In this meihod, it is seen that the bandage of 
Scultetus, and other bandages, or short splints on the 
front or back of the thigh, are dispensed with ; no 
advantage being derived from their use in the ma- 
jority of cases ; whilst we can, owing to their absence, 
examine the state of the fracture ; apply cold washes 
to combat any inflammatory action, and yet not de- 
range the limb by their application. 

BARON BOYER'S APPARATUS, 

Is composed of a splint, of particular construction, 
for extending the limb ; a foot-board ; a padded belt 



232 FRACTURES OF THE FEMUR. 

or perineal band, which is buckled round the upper 
part of the thigh ; two common flat splints of the 
length of the limb, one for the anterior and the other 
for the internal part of the thigh ; and some junct- 
bags, tapes, and wadding. 

The outside splint is about four feet long, and three 
inches wide. Along half its length runs a groove, 
about half an inch broad, the extremity of which is 
covered with iron ; to this groove a screw is adapted, 
which occupies its whole length, one end of it being 
supported against the plate of iron covering the ex- 
tremity of the groove, and the other, made to fit a 
handle by means of which it can be screwed up. On 
the inside of this splint, a contrivance for holding up 
the foot-pieceisfastenedtothe screw, and the upper part 
of the splint is received in a sort of pouch or bag, 
adapted to the external side of the perineal or thigh 
belt. The sole-piece, or foot-board, which has two 
branches at its inferior part, to steady it when resting 
on the bed, is made of iron, and covered with soft 
leather. This is connected by means of a mechani- 
cal contrivance, as just mentioned, with the screw. 
To that part of the sole which is near the heel, is 
attached a broad piece of soft leather, which being 
split on each side into two straps, serves for fixing 
the sole to the foot. 

The perineal band is of strong leather, covered with 
buckskin, and well stuffed with wool ; near the place 
where its two ends are buckled together on the limb, 
a little leather pocket is sewed, for receiving the upper 
end of the external splint. The patient being then 
properly disposed upon the bed, a splint-cloth is 
passed under the limb, and laid upon five tapes. In the 
next place, the perineal band is applied, the surgeon 
having previously surrounded the upper part of the 
limb obliquely with a cushion of wadding, four fin- 
gers' breadth wide, and the length of the thigh-belt, 
or with the junct-bag, in order to moderate the pres- 



FRACTURES OF THE FEMUR. 233 

sure of the latter, and render it more supportable. 
The hollows of the sole of the foot and lower part of 
the leg are also filled up with wadding or tow, and the 

Fi^. 161. 




foot-piece, is fastened to the former, by means of the 
soft leather straps attached to its under surface, which 
pass round the lower part of the leg. Should, how- 
ever, these straps appear insufficient to fix the iron 
sole firmly to the foot, an extra band of calico or linen 
may be applied in the same manner. Fig. 161. 

That done, the surgeon proceeds to the reduction 
of the fracture, and after adapting the upper extre- 
mity of the splint to the pouch of the perineal band, 
the foot-support being connected with the splint, and 
the cushions, and the anterior and internal splints 
applied, the whole is fixed by means of the tapes, 
as in the ordinary apparatus for fractures of the 
thigh. Lastly, by turning the winch, the iron sole is 
lowered, drawing the foot, to which it is attached, 
along with it ; and the superior extremity of the 
splint is pushed upward, and the member elongated 
to the necessary extent. 

DR. HARTSHORNE'S SPLINTS. 

These are generally spoken of as modifications of 
Boyer's, but differ so much from them as to be almost 
entirely new. They are composed of an outer splint, 
long enough to reach from four inches below the heel, 
nearly to the axilla ; and of an inner splint which 



234 FRACTURES OF THE FEMUR. 

goes from the same point, up to the perineum. In 
the lower extremity of each of these is a long mor- 
tise, in which the foot-board slides, or is moved by the 
screw. The upper end of the inner splint is covered 
with a pad of horse-hair, which is again covered by 

Fi^. 162. 



Illlllllllllllllllllllllllllllllllll!l!l!ll! "iiifllllll|i|||l|i||ff 

ggillll 




buckskin. (Fig. 162.) An ordinary gaiter and a hand- 
kerchief complete it. In its application, fix the gaiter 
or band on the foot, and pass the splints on each side 
of the limb till the inner or padded one touches the 
perineum. Then attach the tapes of the gaiter to the 
upper block or foot-board, and by turning the screw, 
draw it down ; the limb following this movement till 
the perineum bears on the pad, when it is stopped, 
and the counter-extension made by means of the pad- 
ded end of the inner splint. 

Junct-bags may be placed between the splints and 
the limb if they press too much against it, but gene- 
rally this is not the case, and in cases of compound 
fracture, where they would be soiled by the discharges, 
it is desirable to omit them. It is chiefly we think, in 
cases of this kind, that these splints can be used to 
the greatest advantage, as the extension and counter- 
extension being kept up chiefly on the inner side, we 
can remove the outer splint and dress the wound, 
without taking the extension off from the limb. Care, 
must however, be observed in the use of this splint, 
that the pressure upon the integuments of the peri- 
neum, does not produce a slough. 



FRACTURES OF THE FEMUR. 



235 



AMESBURY'S APPARATUS FOR FRACTURES OF THE 
MIDDLE AND LOWER THIRD OF THE FEMUR, 

Is divided into three portions, independent of splints 
and straps ; one is for the thigh, a, Fig. 163 ; another 
for the leg, h ; and the third for the foot, c. There 
are two thigh-pieces made to each apparatus, one of 

Fig. 1G3. 




which is bevelled off at the lower end to the right, 
and the other to the left ; so that when one of them 
is fixed to the leg-piece, w^hich is hollowed out to 
receive the back of the leg, the leg and thigh-piece 
together, are adapted to the natural line of the right 
limb ; and when the other thigh-piece is joined to 
the leg-piece, they are adapted to the natural line of 
the left limb. This arrangement Mr. Amesbury con- 
siders necessary, in order to preserve the figure of a 
perfectly formed limb, which is not straight, but 
turns inwards a little at the knee. The leg and 
thigh portions are connected by means of a little steel 
or brass pin, d. Behind the apparatus is a steel bar, 
e, coated with brass, and fixed to the back of the leg- 
piece. To the upper end of this bar is fixed, what Mr. 
Amesbury calls a brass foot, to which is attached a 
bolt acted upon by a spring. There is a hole in the 
centre of this brass foot, which is traversed by the bolt 
in the transverse direction. At the back of each thigh- 
piece is a rack, g^ Fig. 164, with several projec- 
tions, each having a hole bored through the middle, 
for the purpose of receiving the bolt attached to the 



236 FRACTURES OF THE FEMUR. 

brass foot-piece. The foot-piece is so connected 
with the steel bar, that it may be easily fixed upon 
any of these projections. When fixed upon either 



[ • ' 


Fig-. 164. 


/r^E^^ -/ S ^l 


i< 









of these, except that nearest the leg-piece, the leg and 
thigh-pieces become joined together, so as to form a 
double-inclined plane (see Fig. 163) ; the angle of 
which may be varied at pleasure, by altering the 
position of the brass foot-piece from one of the teeth 
or projections of the rack, to another. At the upper 
end of the thigh-piece, is a sliding brass plate, h, Fig. 
164, so adapted that it may be applied to either of the 
thigh-pieces at pleasure. This contrivance allows of 
the thigh part of the apparatus being adapted to thighs 
of various lengths. The upper end of this plate is 
turned off, so that, when it is properly padded, it may 
bear against the tuberosity of the ischium, without in- 
juring the integuments. At the back of the sliding 
plate, are placed a couple of brass bars, i i, which 
answer the double purpose of rendering the sliding 
plate more secure when it is fixed upon the thigh- 
piece, and of preventing the pelvis-strap, to be no- 
ticed presently, from slipping off the apparatus. 
There are little studs, I, placed at the back of the 
apparatus, for the purpose of receiving the straps by 
which it is confined to the limb. 

The pelvis-strap is of leather, furnished with a 
sliding pad, and sufficiently long to reach round the 
thigh, and the pelvis. 

Three short splints long enough to reach from the 
upper end of the thigh to the lower part of the con- 
dyles of the femur, are also required to be placed 
upon the thigh. 



FRACTURES OF THE FEMUR 237 

Application. — The apparatus and splints being 
properly padded, the surgeon places the pelvis-strap 
between the bars and the plate or sliding portion ; 
taking care previously, to apply a single-headed roller, 

Fig. 165. 




d^ as in the cut, spirally about the leg, from the toes 
to the knee. This being done, an assistant takes the 
small of the leg in one hand ; places the other under 
the knee to raise the limb, and at the same time to keep 
the knee bent and the thigh extended, while the sur- 
geon placesthe apparatus under it. When the limb is 
properly placed, the shoe, «, (Fig. 165,) previously 
padded in the inside, is buckled, to the foot, while 
the foot-board, 6, and leg-piece, are placed at nearly 
right angles : in order to give the foot support, and 
steadiness. The leg is then supported along the 
whole of its under surface in order to give it an equal 
bearing upon every point of the apparatus, and this 
is done by means of tow or wadding, c, placed under 
the small of the leg, between the long pad and the 
leg-piece. The leg is then fixed upon the apparatus by 
a roller carried spirally round both from the angle to 
the bend of the knee, or by straps properly padded. 
To confine the fractured parts in their natural posi- 
tion, the assistant takes the apparatus and the knee 
between his hands, and extends the thigh gradually, 
in a line with the thigh part of the apparatus, 
which the surgeon supports against the back of the 



238 FRACTURES OF THE FEMUR. 

limb. Then after coaptating the fragments of the 
bone, he applies the splints ; the first, e, on the 
outer side of the thigh, from the great trochanter 
to the lower part of the outer condyle ; the second, 
on its inner side, reaching from the pubes to the 
lower part of the inner condyle ; and the third, /, 
upon the fore-part of the thigh, from a little below 
the superior anterior spinous process of the ilium, to 
the base of the patella. These splints are kept in place 
by the straps, g g g, fixed to the studs on the back 
part of the apparatus. Lastly, the pelvis-strap, h, is 
to be carried round the limb, under the strips of 
leather of the splints, and made to cross on the outer 
side, while the buckle-end, with the sliding pad, is 
carried round the pelvis and made to meet the other 
end in front, where it should be fastened. The tapes, 
i i, serve for fixing the lower part of the apparatus to 
the foot of the bed. This and others of Mr. Ames- 
bury's apparatus, are thought by him to offer peculiar 
advantages, and as he has written two large octavo 
volumes on the subject of fractures, we would refer 
those desirous of learning his views more fully, to the 
work itself. 

GIBSON'S MODIFICATION OF HAGERDON, 

Consists in two splints half an inch thick, formed at 
the upper extremity like the head of a crutch; five 
inches wide just below this head ; five feet and a half 
long for an adult, and tapering towards the lower end, 
which is about two inches wide. These lower ends 
for the extent of a foot, are straight, and have six or 
eight holes at equal distances, large enough to receive 
a stout peg intended to secure the foot-board. 
Shoulders are made in the splint just above the last 
peg-hole, to prevent the foot-board from ascending. 
The foot-board itself is made of seasoned, tough wood, 
an inch thick, twelve inches long, and nine wide. 
In this are three rows of slits half an inch wide, and 
an inch and a-half long, intended for the straps of 



FRACTURES OF THE FEMUR. 



239 



the gaiters which are to secure the feet to the board. 
Two other slits receive the ends of the splints, thus 
making eleven perforations in the foot-board. The 

Fig. 166. 




gaiters are like Physick's gaiter, with two additional 
straps ; so that there are two near the instep and two 
near the heel, long enough to pass through the foot- 
board, and tie on its back. 

In its application, the bed being prepared, as be- 
fore mentioned, and the patient placed straightly on 
it, the gaiters are applied to both feet, and the frac- 
ture set. The splints with junct-bags, or else the 
splints themselves padded, are then applied and the 
sound limb bandaged all the way up to one splint, and 
the foot-board fastened to both of them. The feet being 
then protected by two small cushions beneath them, 
are to be secured to the foot-board by passing the 
straps through the holes and tying them on the outside ; 
afterwhich,both splints are to be secured to the patients 
body by four or five pieces of bandage (Fig. 166.) 

In this apparatus both limbs are confined, and the 
counter-extension is made at the acetabulum of the 
sound side, by means of the sound limb. Conse- 
quently, we must guard against any bending of the 
sound knee ; as that would at once do away with 
the use of this limb as a splint, and permit short- 
ening. 

A very simple apparatus of the same surgeon, espe- 



240 



FRACTURES OF THE FEMUR. 



cially adapted to the treatment of fractures of both 
thighs, is to be found in the following plan. 

GIBSON'S SIMPLE INCLINED PLANE, 

Is composed of a board sixteen inches wide, two 
feetfour incheshigh, and with six mortises near itsupper 
extremity, which is placed vertically ; whilst another 
board of similar breadth and length, is placed horizon- 
tally ; a third, three feet long, and extending from the 

Fl^. 167. 




extremity of the horizontal one, to within ten inches of 
the top of the upright one, forms an inclined plane, and 
the whole joined together, forms a triangle, (Fig. 167). 
At the lower end of the inclined board, is an open- 
ing six inches wide and eight long, to allow of the 
passage of faeces and urine to a vessel below. There 
are likewise two mattresses ; two foot cushions, and a 
pair of gaiters. The larger mattress, of the length and 
breadth of the inclined board, is two and a-half inches 
thick, and fastened to the board by straps on its edges. 
The smaller mattress, fills up the opening for the pas- 
sage of faeces, &c. The gaiters and foot cushions are as 
before described ; and lastly, there are two round pins, 
each six inches long, which are passed through holes 
in the inclined plane. Then the patient being placed 



FRACTURES OF THE FEMUR. 241 

on this, as seen in Fig. 167, the fastening of the feet 
makes the extension, and the weight of the body the 
counter-extension ; thus placing the limbs in an 
easy position ; in one very favourable to the reduction 
of any inflammation, and especially applicable, to the 
cases of fracture just mentioned. — Where, from pecu- 
liar circumstances, we wish to allow a certain degree 
of motion to the limb, we may find it useful to employ 

PROF. N. R. SMITH'S APPARATUS. 

This consists of four pieces, viz. : two concave-in- 
clined planes, one of which is adapted to the inferior 
surface of the thigh, the other to that of the leg, and 
united by a hinge corresponding with the knee. The 
third piece is for the foot, and the fourth, connected 
to the thigh-piece, extends up the side of the body. 

Fg. 168. 




(Fig. 168.) The limb being placed in it, asin Fig. 169, 
is then to be suspended. This is, however, a somewhat 
complicated apparatus, or at least one that is not 
readily prepared at the moment ; but makes when ap- 
plied, a very light and excellent double-inclined plane. 
The figures give a good idea of it, and those who 
may wish to construct one, will find a minute account 
16 



242 



FRACTURES OF THE FEMUR. 



of it, in all its parts, by Prof, Smith, in Ged ding's 
Baltimore Med. and Surg. Journal, vol. i., 1833. 



Fi^. 169. 




FRACTURES OF THE PATELLA. 243 

CHAPTER VI. 

FRACTURES OF THE PATELLA. 

In transverse fractures, the upper fragment being 
drawn up by the action of the quadriceps femoris, the 
indications in the treatment are, to overcome the action 
of this muscle, and bring the fragments as closely in 
apposition as possible ; in order to shorten the liga- 
mentous union, and thus preserve a more perfect use 
of the limb. To do this, various means have been 
proposed, as those of Dessault, Amesbury, Sir A. 
Cooper, Sir E. Home, Mogridge of Devon, Dorsey, 
Mayor, Gerdy, &c., &c. 

DESSAULT'S APPARATUS, 

Consists of a splint three inches wide, long enough 
to reach from the tuber ischii beyond the heel ; two, 
two and a-half inch rollers eight yards long ; a two 
inch band of the length of the limb, and some tow, 
&c. Then the thigh, being bent on the pelvis, and 
the leg extended on the thigh, the limb is supported 
by an assistant, and the long band placed on the front 
of the limb, and held by other assistants in its place, un- 
til it is fixed by one of the rollers in an ordinary spiral 
bandage up to the knee. Two slits corresponding to 
the knee-pan, are then made in the band, to allow the 
fingers of the surgeon to pass through and bring down 
the upper fragment ; when the roller being resumed, 
should be carried round the joint in several figures of 8, 
and then continued up the thigh, to compress its muscles 
and fix the end of the band. The use of this band is 
now seen to be, to fix the turns of the roller, by pre- 
venting those of the leg from descending, and those 
of the thigh from ascending, and also to guard against 



244 FRACTURES OF THE PATELLA. 

flexion of the knee ; to assist in which, whilst the 
limb is still elevated, the surgeon applies one end of 
the splint under the tuber ischii, and then filling up 
the inequalities of the limb with cotton or tow, ex- 
tends it on the whole back of the leg, and confines it 
to the limb by simple spiral turns of the second roller. 
This apparatus is very simple, but would perhaps 
answer as well without the band, as the roller, if 
properly applied, will certainly not slip after the ap- 
plication of the splint. 

DORSET'S APPARATUS, 

Is also simple, and consists of a piece of wood, half 
an inch thick, three inches wide, and extending from 
the buttock to the heel. Near the middle of this 
splint two bands of strong muslin, about four inches 
wide each, doubled on itself, and a yard long, are 
nailed at a distance of six inches apart. Two ordinary 
rollers, two small compresses, and some tow or soft 
flannel complete the apparatus. Then, whilst an 
assistant raises the limb, as in Dessault's plan, the 
surgeon applies an ordinary spiral, to cover in the 
whole leg and foot, and on reaching the knee, brings 
the fragments as closely together as possible, and 
confines them by figure of 8 turns. He then covers 
in the thigh by the same sort of turns ; places the 
splint properly padded on the back of the limb, and 
fastens it by spiral turns of the second roller. On 
coming to the lower one of the transverse bands, it 
is to be passed above the upper fragment, over the 
compress placed there, and the upper strap passed 
below the lower fragment, and both secured by a pin 
or knot ; when the remainder of the splint is to be 
covered in by the subsequent turns of the roller. 

This apparatus is the same in principle as Boyer's, 
but has the advantage over it of being more simple, 
and easily obtained at a moment's notice; a shingle 
or strip of wood, a few tacks, and a piece of bandage, 
being all that is requisite. 



FRACTURES OF THE PATELLA. 



245 



MAYOR'S METHOD, 

Has been already mentioned under his system, as the 
tarso-patellae handkerchief. 

GERDY'S PLAN, 

Is similar to the uniting bandage for transverse wounds, 
and consists of two strips about half a yard^4ong, one 
of which is cut into three tails, and the other into 
three slits, and used as follows. Place an ordinary 
spiral bandage on the front of the leg as far as the 
knee ; then lay the tailed bandage so that its ends 
may correspond with the lower 
fragment, and fasten it to the leg 
by a second spiral, firmly applied. 
Place a spiral bandage on the 
thigh, and laying the slit bandage 
so that its slits may correspond 
with the upper fragment, bind it 
by another spiral bandage, or by 
turns of the first, also firmly to the 
thigh. Place the two compresses, 
one above the upper fragment, 
the other below the lower frag- 
ment, and passing the tails of 
one band through the slits of the 
other, press upon the compresses, 
and force the fragments into ap- 
position, by fixing the lower one, 
and bringing the upper one to it. 
Then confide the ends of the 
bands to an assistant, and fasten 
them by another spiral of the lower 
extremity, beginning at the ankle 
and reaching to the groin, with 
figure of 8 turns at the knee over 
the whole (Fig. 170). 




246 



FRACTURES OF THE LEG. 



CHAPTER VII. 
FRACTURES OF THE LEG AND FOOT. 



FRACTURES OF THE LEG. 

These whether of one or both bones, with the excep- 
tion of the lower end of the fibula, are usually treated in 
the same way. Here, as in other fractures, various 
means have been proposed, but as the most simple 
one has seldom or ever been known to fail, we shall 
confine ourselves now to a description of it. This 
is the 

APPARATUS OF THE PENNSYLVANIA HOSPITAL, 

And consists of an ordinary pillow, and a fracture- 
box. The fracture-box is made of four pieces of 
wood, the bottom one of which, extending from the 
knee to a little beyond the heel, has fastened to its 
lower end a perpendicular piece for the foot : to its 
sides are attached by hinges, two lateral pieces about 

Fig. 171. 




seven inches wide, and intended to shut up against 
the sides of the limb and foot-board, to form the 
box. Fig. 171. Then, placing a pillow in the box, 
and the limb on the pillow, fasten the foot to the 



FRACTURES OF THE LEG. 247 

foot-board by a simple band over the instep ; tie up 
the sides of the box, and the dressing is complete. 

If it is desirable to apply cold washes, or to pro- 
tect the pillow from discharges, or if it is a compound 
fracture, a piece of oiled silk, or coach curtain, may 
be laid over the pillow. Otherwise it is not required. 

This very simple apparatus is all that is used at 
this large hospital for fractures of the leg, except 
where, from great lateral inclination in fracture of the 
lower end of the fibula, Dupuytren's splint is neces- 
sary. But this is seldom the case ; as the tieing of the 
foot to the foot-board, so as to cause an inclination 
inwards, and a little extra compression made at the 
internal malleolus by meansof a pad of cotton, isaJl that 
is requisite, even here. The principle thing to be attend- 
ed to in fractures of the tibia, is the state of the heel, 
which is very apt to sink on the pillow, and thus cause 
the lower fragment to project anteriorly. We must 
also see that the foot-board projects beyond the toes, 
in order to keep off the weight of the bed-clothes, and 
prevent their causing the same thing by the extension 
of the foot. The band across the instep prevents the 
inclination of the foot to either side, and the pres- 
sure of the pillow against the limb by the sides of the 
box, prevents lateral deviation of the fracture ; whilst 
by this apparatus, we have the parts constantly before 
us, can remedy instantly any deviation, and combat 
inflammation by cold washes, &c. 

A simple rule, by which to tell whether a leg is 
properly set or not, is to see that the edge of the first 
joint of the big toe corresponds with the inner edge 
of the patella. This, even if the patient is bandy- 
legged, w^ill generally keep us right as to the proper 
position of the limb. 

In cases of fracture of the leg, where the contusion 
is a slight one, but accompanied by a wound, attempts 
should be made to close it as soon as possible, and 
promote its union by the first intention. To do this, 



248 FRACTURES OF THE LEG. 

draw it together with adhesive strips, and then apply 
over them a thick piece of patent lint, well wet with 
white of egg, so as to cause it to fit very closely to 
the limb, exclude the air, and form an artificial scab, 
as recommended by Sir A. Cooper. This should not 
be removed for several days. If, however, the wound 
is a serious one, and proceeds to suppuration, no 
dressing is equal to the plan of Dr. Barton. 

BARTON'S BRAN DRESSING. 

This requires a fracture-box ; some bran or fine saw- 
dust, and a little cotton. Then fill the box, with its 
sides shut up, (or have one made with fixed sides,) 
one-third full of bran ; place the limb in it, fasten 
the foot to the foot-board as before, and stuff some 
cotton between the knee and the sides of the box, to 
keep the bran from escaping. Then fill up the box 
with bran, so as to cover in the wound and whole limb. 

This forms a very soft and equable bed for the 
limb, keeps the flies off from the wound, prevents 
the foetor from the discharges, and owing to its ab- 
sorption of the blood or discharge from the wound, it 
swells, make pressure on the part, and thus tends to 
arrest the hemorrhage, or prevent the formation of 
sinuses. After two or three days, if we wish to 
change it, scrape off the bran from the limb, and 
cleansing it from the wound by a spatula or syringe, 
re-apply it fresh. In hospitals, this dressing is espe- 
cially useful, as it preserves the wards from the foetor 
of the discharges, which, without this, are some- 
times almost insupportable. 

It also answers for extensive wounds of the leg or 
thigh, the box, in the latter case, being made to ex- 
tend up to the trochanter of the femur ; and in some 
cases, has certainly prevented erysipelas, by keeping 
the limb from the action of the atmosphere. 

After the bony union in any case of fractured leg 
is tolerably firm, say after six weeks, an ordinary 



FRACTURES OF THE LEG. 249 

spiral bandage should be applied to the limb, and 
over this two splints of binder's board, softened in 
hot water so as to mould themselves to the limb. 
These may be confined there by another bandage, so 
as to strengthen the part before the patient attempts 
to walk about. 

In very oblique fractures of both bones, extension 
and counter-extension is sometimes necessary to pre- 
vent shortening. To obviate this, we should apply 
Physick's modification of Dessault's splints for frac- 
ture of the thigh, or Hutchinson's leg splints, (though 
the first is preferable) till the tendency to spasm of 
the muscles has gone oflf, when the usual means may 
be employed ; but we again repeat, that it is seldom 
any other dressing than the fracture-box is required 
for these cases. 

AMESBURY'S APPARATUS FOR FRACTURES OF THE LEG, 

Is composed of a thigh-piece, properly shaped to re- 
ceive the back of the thigh, having a pair of lateral 
splints connected with it, and some studs for the reten- 
tion of straps ; a leg-piece, immovably connected to 
the thigh-piece at an angle, and hollowed out for the 
reception of thebackof the leg ; and afoot-piece, which 
admits of being so shifted as to adapt the leg-piece 
to the length of the leg. This should not rise higher 
than is suflficient to form a right angle with the leg- 
piece when connected with it. There are some holes 
in each side, and a strap is attached to it, having upon 
one end a buckle, and a shoe with a wooden sole, for 
the reception and retention of the foot, to which are 
attached two straps for connecting it with the foot- 
board. The foot-board is supported by a foot-strap, 
which, when in use, extends from one side of the 
thigh-piece round the lower part of the foot-board, 
where it is passed under a strip of leather placed 
there to keep it in its place, and then carried up to the 
opposite side of the thigh-piece, where it is buckled. 



250 FRACTURES OF THE LEG. 

The apparatus to be used, ought to be first adapted 
to the sound limb in cases of simple fracture of the 
leg, and well padded as in the case of fracture of the 
thigh before referred to ; a small concave pad, too, 
should be placed on the inside heel of the shoe, and 
another pad upon the sole. Two side splints are re- 
quired, the outer one extending from the foot-board 
to the upper part of the outer condyle of the femur, 
and the inner one from the foot-board to the inner 
condyle ; — also a split deal shin-splint ; and in cases 
of oblique fracture, a thin pad to be applied upon the 
instep, covered with a piece of pasteboard, a little 
wetted, which, when dry, serves to equalise the pres- 
sure and keep the instep easy. 

Application. — In the first, or Inflammatory stage, 
the shoe, a, containing the heel and sole-pads, ought 
to be carefully placed upon the foot ; the instep 
pad arranged upon the instep, and the shoe closed 
over it, and firmly confined to the foot, by means 

Fi^. 172. 



of the buckles and straps there attached for that 
purpose. An assistant should next be directed to 
place one hand under the knee, and, taking the foot 
in the other, raise the fractured limb, bringing it round 
so as to let it rest upon the heel. When the limb is 
raised, the surgeon places the apparatus under it, and 
brings the angle of the same, opposite the bend of 



FRACTURES OF THE LEG. 251 

the knee, directing the assistant to lower the limb 
upon the splint. 

He now neatly fixes the shoe, a, to the foot-board, 
6, by means of the straps attached to the sole, and 
by its aid is easily enabled to raise or lower the 
foot according to the length of the heel or thickness 
of the calf, so as to bring the lower portion of the 
fractured bones into a proper line with the upper, as 
far as respects any angular projection backward or for- 
ward, and a padded splint being placed upon the 
front of the thigh, the whole of the thigh-part of the 
apparatus is fixed to the limb by means of the 
straps, c. That done, the shoe fixed to the foot-board 
and the thigh part of the apparatus to the thigh, the 
foot-board may be raised nearly to a right angle 
with the leg-piece, and fastened in this position by the 
foot-strap, c/, care being taken that the heel does not 
bear against the sole of the shoe. The fractured ends 
should next be noticed, and if the foot requires to be 
raised or lowered, it may be done by means of the 
strap which confines the shoe to the foot-board. 

The part of the pad, e, which lies under the small 
of the leg, being now raised and supported in close 
contact with it by means of tow or other soft material 
placed between the pad and this part of the apparatus, 
the whole length of the back of the leg will then 
have an equal bearing upon the apparatus. 

The lateral splints are next to be applied, the long- 
est upon the outer side of the leg, and the shortest 
upon its inner side, the lower ends of these splints 
being fastened to the foot-board by means of nar- 
row tapes passed through the holes at the sides, 
and the upper end kept close to the leg by the cir- 
cular strap, g, passed round the limb over the splints 
and the apparatus. 

With respect to the position of the limb thus fixed, 
it should be placed with the apparatus resting upon the 
heel, and the two planes be well connected, as seen in 



252 FRACTURES OF THE LEG. 

Fig. 172, by means of the steel bar, which forms part 
of the apparatus for fractures of the thigh, the whole 
being steadied by tapes attached to the foot-board, 
and passing off from thence to the sides of the foot of 
the bed. Cooling lotions, leeches, &c., may be ap- 
plied, by unbuckling the circular leg-strap, and throw- 
ing back the side splints. 

When the inflammation is subdued, which is usually 
in three or four days, some strips of soap-plaster, each 
about an inch and a-half wide, should be applied 
round the limb with very moderate tightness, so 
that they may pass from the ankle to a consider- 
able distance above the fracture. The ends should 
then be crossed on the sides or front of the leg, and 
cut off, so as to be easily turned back, when it is ne- 
cessary to observe the state of the skin. Some strips, 
or a short roller, should also be passed round the foot 
to prevent oedematous swelling in that part. When 
this is done, and the side splints re-applied, the shin- 
splint should be properly adjusted, and the whole leg- 
part of the apparatus supported by three circular straps 
and buckles. 

The cross-bar may now be removed, and the appa- 
ratus furnished with a sling or thong of leather fixed 
to the lower end of the leg-part of the splint, by 
means of which the limb may be moved passively at 
pleasure, the patient reclining upon a sofa, or resting 
his leg upon the seat of a chair. He may walk, too, 
with the assistance of crutches, passing in this case 
the sling over the neck, as in the ordinary way ; the 
movements of the limb, however, should be always 
passive, and never by the action of its own muscles. 
In a fortnight or three weeks time, according to cir- 
cumstances, the foot board should be shifted a little 
higher up the leg-piece, so as to press the fractured 
ends together, and hasten their consolidation. 

When both bones of the leg are broken, and the 
fracture of the tibia happens to be very oblique, exten- 



FRACTURES OF THE LEG. 253 

sion must be made until the fibula is united. For this 
purpose, the thigh-piece of the apparatus can be 
pressed up closely against the back of the thigh, and 
the foot-board shifted down, so as to make the space 
between the foot-board and the thigh-piece longer 
than the leg. When the limb is placed on the splint, 
and the thigh-piece fixed, the assistant grasps the 
foot and ankle in his hands, and makes gentle exten- 
sion in the natural line of the bone, so as to bring the 
fractured parts into proper adaptation; this being done, 
the surgeon keeps up the extension by buckling the 
strap, which is fixed transversely to the shoe, round the 
foot-board, taking care that the broken extremities unite 
in the relative position which they naturally occupy. 
For fuller details relating to this part of the treatment, 
the reader is referred to Mr. Amesbury's " Practical 
remarks on the Nature and Treatment of Fractures of 
the Trunk and Extremities." vol. ii. 



DUPUYTREN'S APPARATUS FOR FRACTURES OF THE 
LOWER EXTREMITY OF THE FIBULA, 

Consists of a wedged-shaped cushion, about two-thirds 
filled with bran or cotton, and of sufficient length to 
extend from the malleolus internus to the knee ; — a 
strong splint, about two feet long and three inches 

Fig. 173. 




wide ; — and two single-headed rollers, from four to 
five yards long. 

Then the fracture being reduced, the wedge-shaped 



254 FRACTURES OF THE LEG. 

cushion, with the base directed downward, is to be 
applied along the inner side of the leg. The splint, is 
next to be applied on this, and made to extend about 
four inches beyond the sole of the foot, and these two 
portions of the apparatus be closely confined to the 
limb, above, by one of the rollers passed in spiral turns 
round it, from just below the knee to a short distance 
above the fracture, and thence round the foot and in- 
step in the form of a figure of 8, without allowing the 
turns of the roller to come on the seat of fracture. 
Care should also be taken in applying this roller, to 
draw the foot inward towards the splint, and maintain 
it firmly in the state of adduction : the posterior part 
of the limb being allowed to rest in a state of demi- 
flexion,upon pillows made to form an inclined plane. 
In Fig. 173, the turns of the upper roller do not come 
far enough down ; they should extend to within an 
inch or two of the fracture. 



BOYER'S APPARATUS FOR FRACTURE OF THE OS 
CALCIS, 

Is made of a bit of strong roller, two inches wide, 
and of sufficient length to extend from four inches 
beyond the foot to the lower third of the thigh ; — 
two single-headed rollers, eight yards long, and two 
and a-half inches wide ; — and a strong, well padded, 
pasteboard splint, moulded to the fore-part of the 
foot and leg, and reaching from the roots of the toes 
to a certain distance above the knee. 

Then the foot and leg being held by an assistant, 
the first in the most complete extension, and the 
second demi-fl^exed, another assistant should be re- 
quested to support the thigh, laying hold of it at its 
middle third. The surgeon then proceeds to apply a 
padding of lint, or charpie, over the toes, and extends 
the strip of roller from the instep, along the sole of 
the foot, the back of the leg, and the lower and pos- 



FRACTURES OF THE LEG. 255 

terior part of the thigh, and the band being main- 
tained thus by the assistants, the surgeon equalises 
the posterior part of the ankle-joint, by means of the 
padding, and applies the graduated compresses on 
each side of the tendo-Achillis. Next, taking one 
of the rollers, he fixes its initial end by a few circu- 
lars applied about the ankle, which at the same time 
secures this portion of the band, and reflecting the 
remainder of the latter backward, covers in the 
whole of the foot. He now passes several figures of 
8 about the heel, in order to embrace the separated 
portions of the bone, and maintain them in apposi- 
tion, and then carries the roller to a short distance 
above the knee by a simple spiral bandage of the leg, 
reflecting the upper part of the band downwards, so as 
to fix it by a few horizontal circulars just below the 
knee. In the last place, the padded splint is placed 
upon the fore-part of the limb, and confined by a 
second roller, carried from the roots of the toes to 
the middle third of thigh, and the limb is extended 
over a pillow, so as to form a double-inclined plane. 
In fractures of the Meta-tarsal bones, or of the Toes, 
there is generally more occasion to combat the eflfects 
of injury to the soft parts, than to set the fracture. 
We should therefore, place the limb in a fracture- 
box, and elevate it, to drain the blood from the part, 
applying cold washes, &c., to overcome the injury of 
the soft parts. Caries, is however very apt to follow 
such injuries even under the most favourable circum- 
stances. 

Fracture-bridges, etc., are often spoken of, to 
keep the weight of the clothes off the foot, and special 
directions given for their construction, but nothing 
more is necessary than two halves of a common hoop 
tied together in the centre, as shown in the fracture 
of the thigh, by Physick's plan. 



256 IMMOVABLE APPARATUS, 



CHAPTER VIII. 



OF THE IMMOVABLE APPARATUS, OR STARCH 
BANDAGES. 

Another method of treating fractures of the leg, is 
by the Fecently revived method of Suetin, and Vel- 
peau, or the '' Appareil Immobile." In the use of this 
apparatus, attention must be paid to the nature of the 
case, the constitution of the patient, &c. ; in other 
words, that it is a favourable case of simple fracture, 
and without much contusion. It should also be re- 
collected that the bandages used, are to be washed 
rollers, applied as in the French Spiral, so as to leave 
the heel and toes open to our inspection ; as we may 
then judge of the state of the parts above. In 
applying them, do it with a light hand, in order that 
the bandages may not be too tight, and if the patient 
complains after its application, so as to show suffering, 
the whole must be removed. If thus applied, this dress- 
ing serves a most excellent purpose ; but is liable to 
abuse, without great attention on the part of the sur- 
geon. Indeed several cases have resulted most un- 
fortunately from it, even in the hands of distinguished 
surgeons ; but with proper attention to the points ital- 
icised above, and the manner of applying it, the result 
of the case is more certain. The success attendant 
on those in which I used it, (which were among the 
earliest in which it was tried in the United States,) 
may be best judged of from the following report of 
those treated in the surgical wards of the Pennsylvania 
Hospital, in 1838, at which time, I was the house sur- 
geon. 



OR STARCH BANDAGE. 257 

Case First. — Fracture of both bones of the leg. 

George R , set. 34 years, a shoemaker by trade, 

and of temperate habits, was admitted into the Hos- 
pital, Dec. 25th, 1838, with a fracture of the tibia, 
oblique at its lower third, and one of the fibula at its 
upper third, caused by a fall upon the ice. The 
limb at first was placed in the fracture-box, and 
evaporating lotions used to reduce the inflammation, 
which was considerable. On the third of January, 
seven days after the accident, the immovable appa- 
ratus was applied in the following manner. A 
washed roller being smoothly applied, from the toes to 
the knee, cotton was placed along the spine of the 
tibia, and also in the cavity on each side of the tendo- 
Achillis, to prevent excoriation from the turns of 
the bandage. This was well rubbed over with 
wheat starch, made thick and smooth by being boiled 
for twenty minutes. A second roller was then ap- 
plied from the knee down and also well covered 
with starch. Two pieces of binder's board cut to 
fit the sides of the leg, and extend from below 
the knee to below the malleoli, were soaked in 
water until soft, and being well saturated and 
rubbed with starch, were applied to the leg over 
this, so as to surround the limb, except for the 
breadth of a finger on the front and back ; small cuts 
being made at the lower end. to cause it to fit the 
projection of the malleoli, and also at any other 
point where it bulged out. A third splint, made to 
fit the foot, and slit at the end so as to enable it to 
turn up behind the heel, was then applied to the 
foot ; starched, and secured by a third roller from the 
toes up. This was coated in like manner ; — a fourth 
applied over all, and the dressing completed by 
starch, which kept the whole smooth and tight, with- 
out the aid of pins. 

The limb was now carefully laid in an empty frac- 
17 



258 IMMOVABLE APPARATUS, 

ture-box ; a little cotton placed under the heel, and 
the foot tied to the foot-board, where it was allowed 
to remain for four days, at the expiration of which 
period the whole was dry and hard ; the limb being 
cased as firmly, as in plaster. 

The patient was then kept in bed without any 
other dressing except the splints ; and on the ninth 
of January, thirteen days after the injury, a bandage 
was doubled around his neck ; carried down behind 
the calf of the leg ; then in front of the ankle ; over 
the instep, and round under the foot to the instep 
again, so as to form a sling and raise the foot 
a little from the ground ; when he was allowed 
to walk about with crutches. In this way he con- 
tinued until February 7th, when the apparatus was 
taken off, before the medical class in attendance on 
the practice of the house ; the limb being perfectly 
straight and firm, and without the slightest deformity. 
On the 13th of February, seven weeks after the in- 
jury, the man was discharged. In this instance, the 
apparatus was not touched until the fourth week, 
when a simple roller was applied to tighten it, owing to 
the looseness consequent on the shrinking of the mus- 
cles. One of the objections raised to the use of the 
apparatus was thus readily obviated without injury 
to the patient ; for, as the splints did not meet before 
and behind the leg, it was easy to fold the surplus 
bandage in, without causing any welt on the skin ; 
while the bandage, having been previously washed, 
shrunk but little. 



Case Second. — Fracture of thejihula two inches 
above the joint. 

Patrick D , set. 42 years, a labourer, fell off a 

step on the 15th of January, and fractured his fibula 
obliquely, two inches above the external malleolus. 
Owing to the inflammation, leeches, and the anti- 



OR STARCH BANDAGE. 259 

phlogistic course, with the use of the fracture-box, 
were continued until February 1st, seventeen days 
after the accident, when the apparatus was applied 
as in the preceding case, except, that the splints 
were continued under the bottom of the foot ; being 
slit up so that the fold under the foot did not inter- 
fere with the application of the splint to the sole ; 
thus preventing all motion at the ankle-joint. After 
the apparatus had been dried in the fracture-box, 
with the foot well turned in for five days, the patient 
was allowed to walk about, and on the 10th of Feb- 
ruary, twenty-six days after the accident, he walked 
up to the third story of the house, and was operated 
on by Dr. T. Harris for cataract. On February 21st, 
the apparatus was removed, — there being not the 
least deformity perceptible even to the touch. 

Case Third. — Oblique fracture of both hoiies of the 
kg. 

Patrick C , set. 23 years^ a labourer, whilst 

working on a rail-road on the I8th of January, was 
knocked down, by the caving in of a bank of earth, 
and both bones of his leg braken obliquely, near the 
middle. He was treated in the usual way by the 
fracture-box, until the 27th of January, when the 
starch dressing was applied. January 31st, four 
days afterwards, was allowed to rise and walk by 
degrees, more each day, until February 25th, thirty- 
eight days after the accident ; when the apparatus 
was removed. The limb was perfectly straight, 
without any motion between the bones, and strong 
enough to permit him to walk upon it. In this in- 
stance, the apparatus was not touched until the sixth 
day after its application, when on his complaining of 
its tightness over the instep, the foot was soaked for 
a few minutes in hot water, and, by introducing a 
spatula under the bandage, it was raised sufficiently 



260 IMMOVABLE APPARATUS, 

to free the point of pain. Being then allowed to 
harden, he suffered no inconvenience afterwards. 

The next three cases were fractures of the thigh, 
in which, as there was but the one bone to act on, 
and other objects to be considered than the mere 
support of the fractured ends, it was applied, at a 
more advanced stage of the treatment. 

Case Fourth. — Oblique fracture of the middle of 
the femur, 

Francis McG , aet. 22 years, of good habits, 

fell, on the 23d of November, down the hatchway 
of a vessel, and fractured his clavicle and femur. 
The clavicle was dressed with the usual apparatus, 
and the femur treated by the long fracture-box, fas- 
tened on the double-inclined plane, until January 
14th, fifty-three days after the injury ; when the union 
not being firm, although there was considerable bony 
deposition, the apparatus was applied as follows: — 
A roller was carried smoothly from the toes up to 
the groin, the limb being held up and extended by 
assistants ; this was starched as in the first case, and 
covered by a second roller. A long splint of binder's 
board was then applied, from the tuberosity of the 
ischium to below the knee, on the back part of the 
thigh, and another from the groin to the patella, in 
front, so as to surround the limb entirely, except 
for the space mentioned in the dressings of the leg. 
These were then covered in the same manner as the 
splints in the first case, and a simple roller applied 
from the toes, up to the lower part of the knee, so 
that it could be renewed at pleasure. The limb 
was now laid on a simple-inclined plane, until the 
apparatus dried. Five days were necessary to dry 
it, when the man was allowed to walk about ; the 
limb being supported by the sling before mention- 
ed, and the splint behind preventing all flexion at the 



OR STARCH BANDAGE. 261 

knee. On the 2d of February, about ten weeks after 
the accident, the apparatus was removed, without 
there being found any deformity or perceptible short- 
ening in his gait ; the measurement showing it to be 
but little more than a quarter of an inch less than the 
sound limb ; and on the 7th of February, the patient 
left the hospital. 

Cases Fifth and Sixth. — Oblique fractures of the 
upper third of the femur, 

Thomas H , set. 26, a labourer, fractured his 

thigh at its upper third, December 6th, about fifty 
miles from town. He was dressed in the neighbour- 
hood, and did not arrive at the hospital till the third 
day after the accident, owing to the destruction of 
part of the rail-road. The limb was much inflamed 
and swollen, and was treated at first by the inclined 
fracture-box,* lotions, &c., until January 6th, when 
the starch apparatus was applied to it, and dried in 
the same manner as in the preceding case. On the 
14th of January, the man was allowed to walk about, 
and the apparatus remained untouched, till its re- 
moval, February 12th, there being perfect union, 
and only one-eighth of an inch shortening by close 
measurement, and none perceptible in his gait. 
On the 21st of February, eleven weeks after the in- 
jury, he was discharged. 

The same apparatus was applied to Patrick 

E , (who was admitted February 6th, with an 

oblique fracture, caused by blasting,) on the 19th of 
February, thirteen days after the accident, and ena- 
bled him to sit up in bed five days afterwards, and 
on February 25th, to walk the length of the 
room. On his standing up, he felt too weak to 
walk readily, but had every prospect of doing so 

* Chapman's double-inclined plane, with a fracture-box on it. 



262 IMMOVABLE APPARATUS, ETC. 

shortly. At the time, he complained of no inconveni- 
ence from the dressing, and was able to turn about in 
his bed ; the limb being but little shortened by mea- 
surement over the splints. 

This case got well, but with marked deformity; so 
much so, as to make me resolve never again to ap- 
ply this dressing to the thigh, before there was consoli- 
dation of the fracture. 

The advantages of this apparatus are, that in 
the case of fractures of the leg, it enables the patient 
to move about in fifteen days, with perfect safety. 
But I have never deemed it expedient to apply it 
so early as M. Velpeau has done, owing to the severe 
contusions which complicate most of the fractures to 
which I could apply it. With this restriction, how- 
ever, it might, so far as is proved by the experience 
of these cases, be used in all simple fractures of the 
leg; as few will be found, in private practice, more 
severe than those on which it was tried. 

In hospital practice, it promises to be of great utility, 
by doing away the risk of sloughs on the sacrum, 
from the pressure consequent on the long con- 
finement to the back ; whilst it adds very materially 
to the patient's comfort, by allowing him to rise to a 
window, or to go from one apartment to another. 
In case second, it enabled a man to rise and undergo 
an operation for cataract, in a place where the light 
w^as better, than in his own room. 

Since my residence in the Pennsylvania Hospital, 
I have frequently seen it employed by M. Velpeau, 
in his own wards, as well as by other distinguished 
French surgeons, and do not hesitate to repeat the 
assurance of its utility in such cases of fracture of the 
leg, as have been mentioned. 

But I doubt the propriety of its use in fractures of 
the femur, before there is considerable consolidation. 



PART IV 



CHAPTER I. 

OF THE APPARATUS FOR THE TREATMENT OF 
DISLOCATIONS. 

GENERAL CONSIDERATIONS. 

As dislocations like all affections of the joints, in- 
volve very materially the usefulness of the limb, their 
proper treatment, and consequently the diagnosis of the 
acccident, become a matter of equal importance with 
that of fractures. Indeed, as the structure concerned is 
much more complicated than that of the mere bony 
tissue, it is questionable, whether the reputation of 
the practitioner is not more involved in these cases, 
than in the previous class of accidents. 

It would, however, be foreign to a work of this 
kind, to consider such injuries at length, and we can 
therefore, do little more than hint at the principles 
involved, and the means required for their treatment. 

Like fractures, these accidents are mainly depend- 
ent for a successful termination, on the anatomical 
knowledge of the surgeon ; but they require even more 
caution, and a higher grade of professional skill, be- 
cause the peculiar liability of the structure involved, to 
take on inflammation, necessitates a resort to means 
generally included under the province of medicine ; 
in other words, requires the skill, of both the physi- 
cian and surgeon combined. 

Lined by a synovial membrane ; strengthened by fi- 



264 APPARATUS FOR DISLOCATIONS. 

brous tissue; surrounded by muscles, and often attended 
by important nerves and blood-vessels: the effects of a 
high degree of inflammation, are nearly always destruc- 
tive to the tissue concerned ; so much so, that it is by 
no means uncommon for old, unreduced dislocations, to 
convert the parts around the point of pressure, into 
bone itself, thus completely modifying the action of 
the limb. This tendency should therefore, always 
be borne in mind by the practitioner. 

But even in making an attempt at reduction, there 
is something more than mere anatomical knowledge re- 
quisite, to overcome the difficulty ; because the distance 
between the origins and insertions of certain muscles 
being materially changed, it follows that some of them 
must be very much stretched, and that as this stretch- 
ing results in spasm, relaxation of the spasm must be 
produced, before there can be any chance of a reduc- 
tion. Here also, resort must be had to medicine 
as well as surgery ; till by means of blood-letting, anti- 
monials, &c., the system be placed in such a state, 
that the use of mechanical means may enable other 
muscles to act in a proper manner. 

Again, as a certain amount of muscular paralysis, 
laceration of ligaments, &c., remain, to a greater or 
less extent, even after the reduction, the use of cer- 
tain means in the after-treatment, is equally important; 
lest there be a recurrence of the accident. 

These points, however, we can merely hint at, and 
must refer those desirous of a more thorough investi- 
gation of the detailed pathology and diagnosis, to larger 
works ; merely giving here such points of practice, as 
may serve the young practitioner for the moment. 



DISLOCATIONS^ ETC. 265 

CHAPTER II. 

ON DISLOCATIONS OF THE HEAD AND TRUNK. 

The general principles involved in this class of in- 
juries, being those just stated, we pass immediately to 
the consideration of the means required in the first of 
the special cases. 

DISLOCATION OF THE LOWER JAW. ' 

This whether on one or both sides, requires that the 
condyle should be freed from the projections of the 
anterior portions of the glenoid cavity of the temporal 
bone, see Fig. 174. 

Fig. 174. 




Reduction. — To accomplish the reduction, the pa- 
tient should be seated on a low chair, and his head 
supported against the breast of an assistant ; whilst the 
surgeon introducing his thumbs within the mouth, 
places them upon the molar teeth, and his fingers 
underneath the chin ; so that he may depress the pos- 



266 DISLOCATIONS OF THE 

terior portion of the jaw by the pressure of his thumbs, 
and elevate the chin by that of his fingers. These 
movements, by freeing the condyles from bony promi- 
nences, will generally enable the muscles to draw the 
bone into its place. But as they frequently do this 
with great violence, and thus pinch the fingers very 
severely, the surgeon should slip his thumbs oflf the 
teeth to the outside of the gums, as soon as he finds 
the jaw begin to yield to his movements ; or wrap 
them well, before introducing them into the mouth ; 
or direct the assistant to place a fork-handle, or plug 
of wood between the teeth of the patient, in order to 
prevent their being bitten. 

After-treatment, — The after-treatment consists in 
the application of any of the bandages before referred 
to, under the head of Fractures of the Jaw ; in keep- 
ing the patient on soft food for several days after the 
reduction, and in directing him to avoid biting hard 
substances for some weeks subsequent to the accident, 
lest it again occur. Should inflammation of the joint 
supervene, it must be counteracted by the antiphlo- 
gistic treatment. 

DISLOCATIONS OF THE OBLIQUE PROCESSES OF THE 
VERTEBRA, 

Are so liable to produce death by pressing upon the 
spinal cord, especially in those of the neck, that it is 
better as a general rule, to permit the deformity to 
exist, rather than endanger the life of the patient by 
attempting its reduction. 

DISLOCATIONS OF THE RIBS, 

Are said to occur at their posterior and anterior ex- 
tremities, although many authors doubt the possibility 
of the first, without its being accompanied by fracture. 
In either case, the bandage directed for the treatment 
of fractures of the ribs, will be as much as we can 
employ for their reduction ; the compresses being 



HEAD AND TRUNK. 



267 



placed over the dislocated extremity, in order more 
effectually to retain it in its natural position. 

DISLOCATIONS OF THE CLAVICLE, 

May occur either at its sternal or humeral extremity. 
The Sternal end may be dislocated, either forwards, 
backwards, or upwards ; and requires that the shoulder 
should be carried in the opposite direction to that in 
which the sternal extremity rests, whilst the bone is 
at the same time, drawn off from the sternum by using 
the humerus as a lever ; on the same principles as 
those laid down by Dessault, in his bandage for the 
reduction of a fracture of the bone. 

Fi^. 175. 




Reduction. — The patient being seated, the surgeon 
should stand at his side, and placing his foot on the 



268 DISLOCATIONS, ETC. 

chair orbed on which the patient rests, with his knee 
in the axilla, bend the arm over his knee as a fulcrum 
with one hand, and with the other force the shoulder 
forwards, backwards, or upwards, according to the 
position of the sternal extremity. (See Fig. 175.) 

After-treatment. — This consists in the use of Fox's 
sling, or the 2d and 3d roller of Dessault, for some two 
or three weeks. 

DISLOCATIONS OF THE HUMERAL EXTREMITY OF THE 
CLAVICLE, 

May be either above, or beneath the acromion process 
of the scapula, and is easily reduced when the shoul- 
der is drawn outwards, by acting on the humerus as 
a lever. But though the reduction is easy, the after- 
treatment will be found very difficult, in consequence 
of the small articulating faces concerned, giving rise 
to a constant recurrence of the injury. The only 
means that we have found certain for the retention of 
the bone in its position, after the reduction, is the 
Spica Bandage of the Shoulder, (Fig. 53,) with a large 
compress directly over the acromion, and the use of a 
sling to the elbow, to keep up the head of the 
humerus. 



DISLOCATIONS, ETC. 269 

CHAPTER III. 
ON DISLOCATIONS OF THE UPPER EXTREMITY. 

DISLOCATIONS OF THE HEAD OF THE HUMERUS. 

These usually occur in three directions ; either into 
the axilla ; under the pectoral muscle ; or, on the dor- 
sum of the scapula ; and require, as a general rule, 
the application of the extending force, in the line 
that the limb naturally takes whilst dislocated. Thus, 
if the head of the bone is in the axilla, draw the arm in 
the line of the body ; if under the pectoral muscle, off 
from the body ; if on the dorsum scapulae, across the 
chest ; or elevate it so as to throw the head of 
the humerus into the axilla, and then draw parallel 
with the body. There is, however, some difference 
in the amount of force required, and the means of 
applying it, according as the case is recent or old ; in 
a strong muscular patient, or in one of less power and 
more delicate frame. 

Reduction. — The simplest means, and generally 
applicable only to cases of very recent occurrence, or 
of but slight muscular development, are those repre- 
sented in Fig. 175, and just spoken of under dis- 
locations of the clavicle. The cut explains itself. 

The next plan is, for the surgeon to place the heel 
of his foot (without his shoe) in the axilla of the pa- 
tient, in order to make counter extension, and then 
draw upon the arm by seizing the patient's wrist, or by 
grasping a towel fastened to the wrist or the lower end 
of the humerus, as represented in Fig. 176. If his 
own strength is not sufficient, assistants may lay hold 
of the towel, behind thehands of thesurgeon, and assist 
the extension. But should the patient be muscular, 



270 



DISLOCATIONS OF THE 



a solution of tart, emet., and such other means as will 
induce faintness and muscular debility, will also pro- 
bably be required. 

Fig. J 76. 




In old luxations, or in well developed subjects, 
even greater force than this may be necessary, such 
as the application of pullies to the humerus, and the 
use of more powerful means of making counter-ex- 
tension on the scapula. Indeed, where pullies are at 
hand, the surgeon will often save himself much hard 
work, by employing them in the first instance. In 
order to use them, attach the towel or band to the 
lower portion of the humerus by means of a clove- 
hitch, (as shown hereafter,) and jfastening the hook of 
the pulley in the other end of the towel, place a 
sheet or padded strap around the scapula, as repre- 
sented in Fig. 177. The extension may then be made 
either in the position exhibited in that cut, or with the 
patient lieing down, as in Fig. 176. In the appli- 
cation of these means of reduction, much will depend 
upon the scapula being firmly fixed, and where the 



UPPER EXTREMITY. 



271 



padded strap cannot be had, a narrow band should 
be applied to the acromion scapulae, in addition to the 
sheet used to fix its lower portion. As the axillary- 
vessels and nerves are apt to be acted on by the force 
employed to reduce the bone, their position should 
always be borne in mind. (See Gibson's Surgery.) 

Fig. 177. 




After 'treatment. — Keep the head of the humerus 
perfectly at rest, by means of a sling, for three or four 
weeks, until the laceration of the capsular ligament 
has united, and combat the subsequent inflammation 
by leeches, &c., when required ; cautioning the patient 
against elevating the arm for many weeks after the 
accident, lest he reproduce the injury. 



DISLOCATIONS OF THE FOREARM, 

May be divided into those of both bones, forwards or 



272 DISLOCATIONS OF THE 

backwards, and into dislocations of the head of the ra- 
dius alone. 

As the first dislocation, viz. both bones forwards, 
requires the fracture of the olecranon, the treatment 
should be the same as that directed for this injury. 
In the dislocation of both bones backwards, the ole- 
cranon, resting on the posterior surface of the lower 
portion of the humerus (Fig. 178), requires that suf- 

Fi£: 178. 




ficient flexion be made, to bring it down into the sig- 
moid cavity of the humerus, and free the head of the 
radius from the condyles. 

Reduction. — To accomplish this, an assistant 
should make counter-extension by seizing the middle 
of the arm, whilst the surgeon, making extension at 
the wrist, puts his knee in the bend of the arm, and 
flexes the forearm upon his leg ; or, bends it around 
a bed-post, or upon the hands of assistants. 

After-treatment. — He then should apply a roller 
from the fingers up to the middle of the arm, and dress 
the case with an angular splint, as directed for frac- 
tures of the condyles ; making passive motion every 
three or four days, to guard against anchylosis. 

DISLOCATION OF THE HEAD OF THE RADIUS, 

May also be either forwards or backwards, producing 
either fixed pronation, or supination of the hand. 



UPPER EXTREMITY. 273 

Reduction. — When dislocated backwards, as is 
most commonly the case, the hand being strongly 
pronated, should be raised by the surgeon and forci- 
bly supinated with one hand, whilst with the other 
he presses the dislocated extremity from behind for- 
wards, assisting this movement by slight flexion of 
the elbow. If extension and counter-extension are 
required, an assistant should make counter-extension 
by seizing the arm, whilst extension is made at the 
wrist by the surgeon, who also forces it into supination. 
If dislocated jTort^arc^^, the manipulations of the sur- 
geon are of course to be reversed. 

After 'treatment. — Place the arm in a sling, or on 
an angular splint, and keep it at rest ; combating in- 
flammation, and also any tendency to anchylosis. 

Although the Elbow-joint is comparatively superfi- 
cial, and the prominences of the different bones com- 
posing it sufficiently evident in its natural state, yet 
is it among the most difficult of the joints in which to 
diagnosticate an injury, in consequence of the swell- 
ing which so rapidly ensues. Fractures of the con- 

Fig. 179. 




dyles of the humerus ; fracture of the coronoid process 
of the ulna ; dislocations of different kinds, and simple 
contusions, have all not unfrequently been thought 
by different surgeons, to exist in the same case. A 
simple rule, which we learned under Velpeau, and 
18 



274 DISLOCATIONS OF THE 

the accuracy of which we have frequently tested, in the 
diagnosis of these injuries, is the following. Carry an 
imaginary circle round the elbow from the external to 
the internal condyle, and when the forearm is semi- 
flexed, it will include the olecranon process and the 
two condyles, in the normal state ; whilst the removal 
of either of these points out of the circle, will show the 
displacement consequent upon the injury, as in Fig. 
179, where owing to dislocation of the forearm back- 
wards, the olecranon is above the circle spoken of. 

DISLOCATIONS OF THE BONES OF THE FORE-ARM ON THE 
WRIST, 

Are usually reduced by the application of force to 
the front or back of those of the forearm, accord- 
ing to the dislocation. But as the laceration of the 
ligaments here, involves a joint peculiarly liable to 
disease, perfect rest for several weeks, strict anti- 
phlogistic remedies, &c., should be insisted on ; par- 
ticular attention being given to guard against anchy- 
losis. The frequency of fracture of the lower end of 
the radius, and the liability to mistake it for a dislo- 
cation of this part, should also be borne in mind. (See 
Barton's fracture of lower end of radius, p. 210.) 

DISLOCATIONS OF ALL THE BONES OF THE WRIST, 

Are seldom seen, except when complicated with such 
severe injuries of the soft parts as may require ampu- 
tation of the limb. But the Magnum alone, may be 
forced out of the cavity formed by the scaphoides and 
lunare, so as to project on the back of the joint. 

Reduction. — Press firmly on the head of the mag- 
num. 

^fter 'treatment. — Apply a compress over it and bind 
the hand firmly to a splint applied on its palmar surface. 
This should extend up to the arm, so as to keep the part 
at rest until the ligaments are united, or strengthened. 



UPPER EXTREMITY. 



275 



DISLOCATIONS OF THE METACARPAL BONES, 

Are very seldom seen, except in that of the thumb ; 
the treatment of which may be included in the con- 
sideration of 

DISLOCATIONS OF THE PHALANGES. 

These may be either on the metacarpal bones, or on 
each other. Let us, however, take the dislocation of 
the first phalanx of the thumb, upon the metacarpal 
bone, as indicating the treatment of all these cases. 

Reduction. — The phalanges being too short to 
enable us to get a hold on them, the surgeon should 
first surround the bone with a piece of buckskin, and 
apply over this, a piece of tape tied in a clove hitch. 

jPig. 180. 




Then, seizing the tape, make extension ; pulling gra- 
dually downwards, so that the extremity of the phalanx 
may describe the arc of a circle, and thus free its up- 
per portion from the projecting metacarpal bone ; 
counter-extension being made by assistants at the 
wrist or forearm, if required. Should the difficulty 
of the reduction seem to be owing to the tension of 
the lateral ligaments, the internal one may be divided 
by introducing a narrow, sharp-pointed knife or 
needle, and dividing it by a sub-cutaneous incision. 
After-treatment, — As in fractures of the pha- 
langes. 



276 DISLOCATIONS OF THE 

THE CLOVE HITCH, 

Just referred to, offers one of the most certain 
means with which we are acquainted, of applying 
an extending force to a limb, and is, we think, 
far preferable to the wet rollers, and other means 
of fastening the extending bands so commonly re- 
commended. In dislocations of the humerus, or 
thigh, it will be found especially useful, and as we 
have never seen it slip, we believe that it never will, 
— if properly applied. Though long recommended 
for the thumb, our attention was first called to its ap- 
plication to other parts, by a sailor in the Pennsylva- 
nia Hospital, in 1837, with a dislocated hip ; who, 
seeing all the usual means of fastening the extending 
band slip and fail, just as the bone was nearly re- 
duced, suggested that he should be allowed to tie the 
sheet himself, which he did in a clove hitch, so that 

Fig. 181. 




it held firmly and relieved him of his injury. Since 
that time we have employed it, and seen it employed, 
in numerous cases without its slipping; and have 
always been pleased with the result. Sanctioned, as 
it now is, by Mr. Fergusson, we hope to see it sup- 
plant the miserable means of the wet roller, and thus 
save a great expenditure of time and trouble. 



UPPER EXTREMITY. 277 

To make it, practice with a piece of twine until the 
turns are learned, as follows: — Turn the slringfrom right 
to left so as to form a circle, and bring one portion of 
the cord in front of the other, as in the right hand turn 
of Fig. 181. Then make a second turn of another por- 
tion of the twine, and twist it so as to place it be- 
hind the first turn, as in the left hand portion of the 
figure. On drawing on the ends, the loops will be 
tied so tight, that the cord will break before the knot 
will slip. After learning these turns of the knot with 
twine, no difficulty will be experienced in making it 
with a sheet or towel, in various other ways. 



278 DISLOCATIONS OF THE 

CHAPTER IV. 

ON DISLOCATIONS OF THE LOWER EXTREMITY. 

DISLOCATIONS OF THE HIP-JOINT, 

Nearly always throw the head of the femur out of 
the acetabulum into some unnatural position upon the 
innominatum. As the sides of the acetabulum project 
considerably above the surface of the ilium, we require, 
in addition to the usual extending and counter-extend- 
ing bands, a lateral band, to be applied on the inside of 
the thigh, nearitsupperthird, in order to drawthefemur 
off from the pelvis, and free the head of the bone from 
the acetabular prominences. This band has not been 
represented in the cuts, owing to the difficulty of 
doing so, without confusing the drawings in the works 
from which they have been copied ; but its action is 
so simple, that we think it cannot be misunderstood. 
As the means employed for the reduction of the four 
different dislocations of this bone, vary only in regard 
to the line of extension, (which, it should be recol- 
lected, is generally to be made in the line which the 
dislocated bone naturally takes,) we shall confine our 
description to the dislocation upwards on the dorsum 
of the ilium, as the most common. The pullies be- 
ing required in most cases of dislocation of the femur, 
and as even with these the reduction is a matter oi 
considerable difficulty, it will save much useless ex- 
penditure of strength on the part of the surgeon, to 
apply them at once, without attempting other means. 
But where pullies cannot be obtained, the plan of Dr. 
Fahnestock, of Pittsburgh, reported by Prof. Gilbert,* 

* Amer. Journal Med. Sciences, No. viii., April, 1845. 



LOWER EXTREMITY. 279 

of using the power furnished by twisted rope, will be 
found to form an excellent substitute. 

The mode of application is as follows : — " Place 
the patient and adjust the extending and counter- 
extending bands, as for the pulleys ; then procure an 
ordinary bed-cord, or wash-line, tie the ends together 
and again double it up on itself; then pass it through 
the extending tapes or towel, doubling the whole 
once more, and fasten the distal end, consisting of 
four loops of ropes, to a window-sill or staple, so that 
the ropes are drawn moderately tight ; finally, pass a 
stick throughout the centre of the doubled rope, di- 
viding the strands equally by it. Then revolving the 

Fig. 182. 




stick as an axis or double lever, the power is pro- 
duced exactly as it should be in such cases ; namely, 
slowly, steadily, and continuously ; which, with the 
aid furnished by the surgeon to the immediate seat of 
lesion, and to the system in general, cannot fail to 
conduct the case to a happy issue." The cut shows 
fully the manner of its application. 

But when we propose to employ pullies, proceed 
as follows, to the — 

Reduction. — Fasten a roller-towel, or sheet, upon 
the low^er end of the femur by a clove hitch. Attach 
the pullies to the free ends of the towel, and fasten 
the hook of their opposite extremity to a staple, bar, 



280 DISLOCATIONS OF THE 

or other fixed point. Place a sheet thickly folded, in 
the perineum of the sound side, to make counter-ex- 
tension ; another across the pelvis from the ilium of 
the injured side, and a strong towel on the inside of 
the injured thigh, in order to draw the head of the 
femur off from the pelvis. Then, seeing that the 
bands are firmly fixed, and the patient's system re- 
laxed by constitutional means, direct the assistants to 
pull slowly but steadily on the pullies, until the coun- 
ter-extending band and the transverse pelvic band be- 
come quite tense and the muscles begin to yield to the 

Fig 183. 




power acting on them. Then the surgeon, seizing the 
leg by the ankle, should use it as a lever, to produce 
rotation of the head of the femur, and directing another 
assistant to draw strongly upon the towel which is on 
the inside of the thigh, continue the use of these dif- 
ferent forces until the parts seem relaxed ; when, or- 
dering the extension to cease suddenly, the bone will 
probably be drawn into its socket. Should the muscle 
however not do so, a repetition of the same means will 
frequently succeed, although at first they failed. 

After-treatment. — Tie the thighs together, and 
keep them at perfect rest ; combating any inflamma- 
tory symptoms that may arise. 

The line of direction of the extending force in the 



LOWER EXTREMITY. 281 

other dislocations of the femur will be evident from 
the following cuts. 



In the Dislocation on the Pubis, the limb is to be 
carried off from the body and placed as in Fig. 184, 
with the addition of the towel to the inside of the 
thigh. 

In the Dislocation into the Sciatic Notch, the 
limb should be carried in the opposite direction, that is, 
over the sound limb, and rotation practised by acting 
on the leg. The inside femoral towel is not required 
here — see Fig. 185. 

Fig. 185. 




Various other means and modifications have been 
recommended for the reduction of these dislocations, 
but those referred to above, will, we think, be found 
sufficient in most cases, and have the sanction of some 
of the highest authorities in the profession. 



282 



DISLOCATIONS OF THE 



In the Dislocation INTO the Foramen Thyroideum, 
the application of the extending force as represented in 

Fi^. 186. 




Fig. 186, has advantages, in some cases, and the 
sanction also of Sir A. Cooper. The principle of its 
action may be seen at a glance. 



dislocation of the patella, 

Can only occur laterally, without laceration of the 
quadratus femoris, or ligamentum patellae. 



LOWER EXTREMITY. 283 

Reduction. — In the lateral dislocation, the surgeon 
should place the heel of the patient on his shoulder, 
and pressing with his fingers on the edge of the pa- 
tella, force it inwards or outwards, according to the 
character of the accident. 

After-treatment. — Keep the limb extended for a 
few days, and direct the patient to wear a knee-cap 
or bandage (Fig. 91) for some weeks afterwards. 

DISLOCATIONS OF THE HEAD OF THE TIBIA, 

May occur in either of four directions ; forwards, 
backwards, inwards, and outwards. In either case, 
we should proceed as follows. 

Beduction. — Extension being made by the hands 
of assistants at the lower part of the leg, and counter- 
extension at the inferior portion of the thigh, the sur- 
geon should seize the condyles of the femur with one 
hand, and the head of the tibia wdth the other, and 
press them in opposite directions, as soon as he judges 
that sufficient extension has been made to enable the 
bones to take their natural position. 

After 'treatment. — Keep the limb extended, and 
combat the inflammation of the joint, which is fre- 
quently very great. The use of a splint, bandages, 
&c., may be required for some time, in order to insure 
perfect rest, and keep down inflammation. 

DISLOCATIONS OF THE FIBULA, 

At either extremity, are so rare, except when accom- 
panied by fracture, that we have little to say about them . 
When the luxation of the lower portion of this bone 
is accompanied with fracture of the tibia, it will re- 
quire considerable attention to save the ankle joint. 

DISLOCATIONS OF THE BONES OF THE TARSUS, 

Like those of the carpus, are generally the result of 
such violence, as implicates very seriously the soft 



284 DISLOCATIONS, ETC. 

parts, inducing such violent inflammation as re- 
quires the greatest care, to avoid the necessity of 
amputation. Their treatment, consequently, could not 
be properly considered here, and the reader is therefore 
referred for them to the books on Surgery. 

DISLOCATIONS OF THE METATARSAL BONES AND 
PHALANGES, 

Resemble very closely the same injury to the bones 
of the hand and should be treated accordingly. See 
page (275.) 

But it must be recollected that if the joint of a toe 
remains unreduced, the pressure of the boot upon the 
projecting point will be liable to keep up a constant 
ulceration, which has sometimes been so troublesome 
as to induce the patient to submit to amputation 
rather than endure it. 



/ 



PART V. 



OF THE MINOR SURGICAL OPERATIONS. 

The diversity of opinion existing, in regard to the 
definition of Minor Operations, leaves this portion of 
the field so open, that every thing not constituting a 
capital operation, might with propriety be here con- 
sidered. Not wishing however, to become too ex- 
tended in our remarks, nor yet to pretend to limit the 
range of subjects, we here merely define our own posi- 
tion, and shall treat under this head of such operations, 
as usually fall to the young practitioner, or within 
the range of every medical man ; such as Blood-letting, 
Issues, Vaccination, Extraction of Teeth, Catheterism, 
Incisions, Means of Arresting Hemorrhage, &c., &c. 



CHAPTER I. 

OF BLOOD-LETTING. 

By this term, we understand the use of every means 
of taking blood from the body, employed with the view 
of relieving or curing disease. These operations may, 
therefore, be divided into several kinds, according as 
they are practised upon the superficial veins by means 
of lancets, leeches, cups, &c., or upon the arteries. 
When the extraction of blood is made by a single 
opening, cut in one of the veins, it takes the name of 
Phlebotomy, or General Blood-letting ; when from an 
artery, that of Arteriotomy ; and when done by the 



286 



BLOOD-LETTING. 



aid of leeches, or cups, it is especially designated as 
Local Bleeding. First — 

OF PHLEBOTOMY, OR VENESECTION. 

This operation is practised upon the veins of various 
parts of the body, as at the bend of the arm, the back 
of the hand, the leg, and of the neck ; though the first 
is by far the most common. At the point where this is 
performed, we find generally five veins, arranged so 
as to form a figure not unlike the letter M. These 
are, the Cephalic, the Basilic, the Median, the Median 
Cephalic, and Median Basilic, a slight reference to the 
surgical anatomy of each of which will be necessary, 
before proceeding to the steps of the operation. 

The skin in front of the bend of the arm being smooth, 
soft, and thin, these veins are generally seen bulging 
through it,or indicated by dark blue prominences. When 



Fig. 187. 




not thus seen naturally, they 
may be rendered more ap- 
parent, by the ligature ap- 
plied above the elbow, pre- 
vious to the operation, (Fig. 
187) or may be known by 
their elastic feel, and by 
their swelling under the fin- 
ger, when filled by friction 
oftheforearm. — Underneath 
the skin we have the adi- 
pose tissue, which varies 
considerably in its amount, 
but is never wholly wanting. 
As the superficial veins or 
those opened in venesec- 
tion, lie between this adi- 
pose tissue and the fascia 
covering the muscle, the 
amount of fat, consequently 
affects materially the opera- 
ration. Beneath the fascia, 



BLOOD-LETTING. 287 

yet only at the depth of two lines, or thereabouts, 
lies the brachial artery, or sometimes, the radial or 
ulnar, according to the point of division of the bra- 
chial into the latter. Of the five veins before re- 
ferred to, the Cephalic, is on the outside ; the Basilic 
on the inside ; the Median in front of the arm ; and 
the Median Cephalic, and Basilic, run from the middle 
to either side, to join the main trunks. The External 
Cutaneous and the Internal CutaneousNerves, are those 
mainly liable to injury ; but their position varies so fre- 
quently, that we cannot pretend to give even a refer- 
ence to them, as it would be inadmissible, in what is 
only intended for an outline ; it being expected that in 
this, as in other operations, the anatomy of the part will 
be learned before operating. 

As from the great variety existing in the arrange- 
ment of the vessels of the arm, it would be almost im- 
possible to designate every spot where some unexpect- 
ed accident, especially the wound of a nerve, may not 
occur, we can only point out, in general terms, the 
best mode of operating, and then refer to the acci- 
dents likely to arise from it, and their means of cure. 

The easiest vein to bleed in, at the bend of the arm, 
on account of its size and fulness, is the median basilic, 
but it is at the same time, more dangerous than the 
median cephalic, on account of the position of the 
artery. This latter, may, however, generally be felt 
pulsating, and by opening the vein by a slightly hori- 
zontal cut, or by moderately flexing the arm, especially 
if the operator is cautious in his movements, there is 
but little risk of injury to this vessel. Some bleeders 
recommend turning the hand into strong pronation, as 
likely to avoid accidents, either by throwing the mus- 
cles more over the artery on the cephalic side, or re- 
laxing the fascia, and making it more difficult to cut, on 
the basilic side. The risk of wounding the tendon of 
the biceps, is not worthy of consideration, compared 
with the safety of the artery. 



288 BLOOD-LETTING. 

The varying position, however, of both arteries and 
nerves, render it difficult to foretell their injury, 
and the general rule, is, therefore, to take the vein 
that is fullest, provided the artery is not too near, and 
leaves the nerves to chance. In several hundred 
cases, we have never met with the slightest accident ; 
whilst others, who were probably, equally, if not better 
informed than ourselves, have experienced consider- 
able inconvenience. In thin subjects, owing to the 
deficiency of adipose tissue, the veins are nearer the 
skin, but being also looser, are more liableto roll under 
the lancet ; whilst in fat persons, they are more firm 
and less moveable, although less readily seen. The 
depth of the incision must always therefore be regu- 
lated by the obesity of the patient. It will also be 
found advantageous to accustom ourselves to bleed 
by the touch, rather than the sight, and to practice 
the fingers on deep-seated veins, or those in fat arms, 
until we can distinguish the elastic feeling of a vein 
from the tenseness of a tendon, or the pulsating cord 
of an artery. With a view of softening the skin, and 
rendering the touch more delicate, some bleeders 
moisten the finger in the mouth before searching for 
the vein. It is, however, a filthy practice, and one 
that is of little assistance ; if the finger of the operator 
is not sufficiently delicate in its touch, he may soak 
it in warm water, but not spit on it. The risks of the 
operation will be treated of hereafter. 

Previous to bleeding at the bend of the arm, a sim- 
ple circular bandage, or a ligature, should be placed, 
with moderate firmness, just above the elbow, so as 
to arrest the circulation in the veins. It must not, 
however, be so tight as to arrest that in the arteries, 
as may be always told by placing the fingers on the 
pulse. After a certain amount of friction to fill the 
veins, the forearm is either held in an extended posi- 
tion by an assistant, or placed between the chest and 
the bend of the surgeon's arm; or in his axilla ; or the 



BLOOD-LETTING. 289 

patient may rest his hand on the top of a stick. The 
surgeon then feels under the vein, by making firm 
pressure on it, for the position of the artery, and if it 
is felt pulsating, should open the vein selected, by a 
more horizontal cut than is usual ; or choose another 
vein ; or change the relative position of the vein and 
artery by strongly pronating the hand, as before stated. 
He then places the thumb or fingers of his left hand, on 
the vein, below the point at which it is to be opened, 
in order to steady it : and holding the lancet in his 
right hand, and facing the patient, if he is bleeding 
in the right arm, or in the right hand, with his back 
to the patient if in the left arm, he cuts through the 
integuments, and opens the anterior parietes of the 
vein ; still pressing on the vein, below the opening, 
with his left hand. The basin or cup to hold the 
blood being previously placed, and the clothes around 
protected by a sheet, he then removes his hand from 
off the vein, and immediately the blood flies into the 
bowl. This pressure with the fingers of the left hand 
below the orifice, will be found to be a neater plan, 
than that of allowing the blood to escape imme- 
diately after the vein is opened ; as it protects the 
clothes or bed from the blood. 

The Lancets with which we may bleed, are of 
two kinds, viz. : the Spring and the Thumb Lancet ; 
either being used, according to the views of the ope- 
rator or the wishes of the patient. 

The Spring Lancet is an old German instrument, 
of some 300 years date, and consists of a metallic 
case, on the outside of which is a trigger, whose point 
is inserted under a spring, when the instrument is set. 
Below the spring, on the inside, is placed the fleam or 
blade, which is drawn up to the spring previous to 
its being used. Occasionally, another and smaller 
spring is placed on the inside, under the fleam, in 
19 



290 BLOOD-LETTING. 

order to keep it constantly in contact with the spring 
moved by the trigger; but it is an unnecessary addition. 

The Thumb Lancet, also of very ancient origin, is 
made of a simple piece of steel, fastened between 
two handles, and intended to be pushed into the 
vein by the hand of the operator. Three kinds are 
employed, viz., the barley-corn or obtuse-pointed ; the 
spear or oat-pointed ; and the serpent-tongued, al- 
though the last is now" nearly obsolete. 

Considerable diversity of opinion exists, both in the 
minds of patients and operators, as to the advantages 
of these instruments, and the prejudices of some are 
so strong against the Spring Lancet, as to prevent its 
use, and vice versa. In some parts of Europe, as in 
England, France, &c., and in the Eastern and Northern 
portions of the United States, the thumb-lancet is pre- 
ferred ; whilst in other portions, as in the Southern, 
Middle, and Western portions of our country, the 
spring is almost entirely used. The use of the Thumb 
Lancet is thought by some to require less skill, and 
therefore to be better suited to general use ; but as far 
as our own individual experience goes, the spring is 
attended by the least pain to the patient, and danger 
to surrounding parts. We have known sea-captains, 
super-cargoes, sailors, nurses, and others, who have 
used the Spring Lancet without any accident, who yet 
were perfectly ignorant of the difference between a 
vein and an artery; so we look upon this objection 
as void, whilst very many from too great boldness 
and force, would inevitably transfix the artery with a 
Thumb Lancet; having no idea of the depth to w^hich 
they should go. In skilful hands, the Thumb Lancet 
is probably the most surgical instrument, but it gives 
the patient much more pain ; the vein is more apt to 
roll from under it, and the opening is often not suffi- 
ciently free to prevent thrombus. For ourselves, we 
infinitely prefer the Spring Lancet, as we can bleed 



BLOOD-LETTING. 



291 



with it more horizontally, in cases where the artery is 
near the vein ; give the patient no time to shrink be- 
fore its puncture ; causes him little or no pain ; regu- 
late very accurately the depth to which we go, by 
the height of the fleam above the vessel, and have 
never seen a vein transfixed by it ; as the resistance 
of the integuments, and of the vessel, generally 
overcome somewhat the force of the spring. Even 
in young children, we invariably use the Spring 
Lancet, and although we have operated on those 
as young as eighteen months, have never had any 
difficulty from the operation. Nevertheless, every 
bleeder should be able to employ either, so as to 
yield to the prejudices of a patient, and thus avoid 
drawing upon his own head, the reproaches that might 
ensue upon the occurrence of an accident under dif- 
ferent circumstances. 

If the Spring Lancet is preferred, it should be held 

Fi^. 188. 




between the fore-finger and thumb of one hand, with 
its blade obliquely to the circumference and axis of the 
vein selected ; so that, on the trigger or button being 
touched by the middle finger, the blade may be driven 



292 BLOOD-LETTING. 

into the vein obliquely to its axis, and also a little on 
its side : as we are then less likely to wound subja- 
cent parts. 

If, however, the Thumb Lancet is the one used, 
bend its blade to a right angle with the handle, and 
place it in the mouth, with the point of the blade 
turned from the hand that is to take it. Otherwise, 
when, after completing the preliminaries, we put the 
hand to the mouth to seize the instrument, we should 
be apt to injure ourselves by sticking its point into 
our own hands. 

In using this lancet, seize the blade between the 
thumb and fore-finger of the hand that we prefer, and 
rest the third finger of the same hand on the arm as a 
point of support. Then placing the point of the lancet 
on the vein that we wish to open, push it suddenly 
inwards, upwards, and outwards; depressing the han- 

Fig. 189. 




die in a circle, so as to make a free incision in the 
line before spoken of : and having drawn the amount 
desired, undo the ligature above the elbow, seize the 
skin about the openingbetween the thumb and fingers, 
so as to close the wound, and wiping the arm clean 
from the blood, place a small compress over the 



BLOOD-LETTING. 293 

opening, confining it by adhesive strips, or by a 
figure of 8 bandage of the elbow, as before shown, 
and the patient comfortable. Particular attention 
should be paid to the cleansing of the lancet after 
the operation, in order to prevent difficulty at our 
next call for its use : as a dirty lancet frequently 
causes abscesses of the part, gives rise to phlebitis, 
and endangers the life of the patient. If the opening 
in the skin and that in the vein do not correspond, a 
bloody tumour, called a Thrombus^ will be formed, 
from the blood escaping into the sub-cutaneous cellu- 
lar substance. To remove this, enlarge the opening 
in the skin, and press upon the tumour ; or else leave 
it to be absorbed by nature, assisted by moderate 
pressure. 

In Bleeding in the Hand, the only rule, is to 
open with a Thumb Lancet, that vein which is most 
easily seen ; these are generally the Vena Salvatella, 
or the Cephalic of the Thumb : avoiding the tendons, 
and also guarding against a deep puncture, for fear of 
injuring the parts beneath. 

Bleeding in the External Jugular Vein, is sel- 
dom practised, on account of the danger of the in- 
troduction of air into the vein. In cases however of 
great cerebral congestion, as in apoplexy, or in infan- 
tile convulsions, it is occasionally practised, and we 
think with advantage. When deemed necessary, it 
should be done as follows : — 

Place a thick, graduated compress on the root 
of the vein just above the clavicle, and fix it by a nar- 
row cravat, the ends of which should tie in the opposite 
axilla, Fig. 190; or else apply an oblique bandage of 
the neck and axilla, as before shown : or, we may 
compress the vein with the thumb, though by this 
plan there is more danger of the entrance of air into 
the vein, from the compression being more imperfect. 



294 BLOOD-LETTING. 

If the vein does not become apparent from this com- 
pression, direct the patient to move the jaws as in 
mastication, and, it will soon fill. When filled, open 
it with a Thumb Lancet at its lower third, and place 
a bent card, or other substance likely to form a little 
trough, just below the opening, so as to carry the 

Fig', 190. 




blood off to the receiver, and prevent its trickling 
down the side of the patient. Having taken the 
amount desired, close the orifice, as in the arm, by 
pressure of the thumb and forefinger, and fasten a 
compress over it by adhesive strips before removing 
the compression which filled the vein, as we thus 
ensure the non-entrance of air, which is very apt 
otherwise to prove almost instantly fatal. 

Bleeding at the Ankle, is generally performed, 
in the internal saphena vein just above the malleolus, 



BLOOD-LETTING. 



295 



191. 



where it is very superficial, though it is also occa- 
sionally done in the foot itself, or in the external 
saphena vein. 

Operation. — In order to bleed in this part, we re- 
quire the ligature, &c., as in the other cases, and also, 
a bucket of warm water, in which to plunge the foot 
previous to the operation. The patient being seated, 
the limb is placed in the hot water as high as the 
calf, in order to assist the filling of the vein and ren- 
der it more apparent. After some few minutes, it is 
then to be removed ; the ligature applied about four or 
six inches above the malleolus, and the heel placed 
upon the point of the operator's knee, or on a low stool. 
A thumb lancetbeingpreviouslyheld in the mouth, and 
the vein, steadied as before shown, is then seized with 
the hand which is most convenient, and the vein opened 
by a wound which should be rather longer than the one 
made in the arm, in order to 
give a free discharge to the 
blood, Fig. 191,whichhere 
seldom escapesin a stream; 
it being more commonly 
necessary to replace the 
limb in the warm water, 
in order to facilitate the 
flow of it, than to see 
the blood flow in a jet. 
The wound should not, 
however, be allowed to 
sink into the water, 
but remain just above it, 
whilst the amount of blood 
taken, must be judged of 
by the discoloration of 
the liquid. When sat- 
isfied as to the proper 
quantity, it only remains 
to remove the ligature, wipe the 




limb, and confine 



296 BLOOD-LETTING. 

a compress over the opening by the figure of 8 band- 
age of the ankle. 

The only accident likely to result from bleeding at 
this point is, the wounding of the saphena nerve : the 
arteries being distant. Should the nerve be wounded, 
either in this or any of the other operations, it will be 
shown by pain, by twitchings, tingling, &c. To treat 
this, we should apply a warm poultice ; keep the limb 
at perfect rest for a couple of weeks, and use the 
anti-phlogistic system generally. 

Bleeding is occasionally followed by irritation of 
the edges of the wound ; by abscess, or by erysipelas. 
Any of these will be best combated by the use of 
the above means in the first stage, and such subse- 
quent treatment as the knowledge of each practi- 
tioner will readily indicate. 

From want of proper attention in the selection of 
the vein, or from w^ant of skill on the part of the 
operator, it occasionally happens than an artery is 
opened. This serious accident may be readily told 
by the brighter red colour of the blood ; by its esca- 
ping in jets which are synchronous with the pulsa- 
tions of the heart ; by the blood continuing to flow, 
notwithstanding firm compression of the vein below 
the opening; or by noticing the change in the colour 
of the blood produced by a very firm compression of 
the artery alone, above the ligature. When thus satis- 
fied of the nature of the accident, we should endea- 
vour to guard against our suspicions of it, being 
seen by those around, in order to prevent alarm ; 
and if the state of the health of the patient does 
not absolutely forbid it, let the blood flow till 
fainting is induced, when we may arrest it by a 
firmer compression, than is requisite when the vein 
alone is opened. To do this, make, by means of 
several small graduated compresses, or by a thick 
pyramidal compress, a cone, the point of which 
should rest upon the wounded vessel ; fix it by a 



BLOOD-LETTING. 297 

firm figure of 8 bandage of the elbow, and apply 
the Spiral of the Upper Extremity, from the fingers up 
to the upper part of the limb. This treatment should 
then be continued for fifteen days or more, by which 
time the closure of the opening in the vessel is gene- 
rally effected ; when most probably an operation for 
aneurism will be required, though this is not abso- 
lutely certain : Velpeau and others having seen cases 
in which the opening in the artery closed, without 
there having been at any time sufficient compression, 
to stop the pulsation at the wrist. Let it, however, be 
remembered, that proper attention will enable us to 
avoid this serious accident, and that when it happens, 
it will generally be the fault of the operator. 

Besides the veins above mentioned, bleeding was 
formerly practised in many others, as the occipital, 
auricular, frontal, sub-lingual, dorsalis-penis, &c., 
but the introduction of leeching has done away with 
these operations. Where, however, leeches cannot 
be had, and it is desirable to take blood directly 
from the part, these veins may be opened by ope- 
rating as in other veins. Such operations should 
always be performed with a Thumb Lancet, the ori- 
fices in the external veins being afterwards closed 
by a compress, adhesive strips, &c. ; and that in the 
sublingual, &c., by the application of cold, or salt 
and water, or astringents, &c. 

ARTERIOTOMY. 

This operation, which was practised to some extent 
by the surgeons of the sixteenth, seventeenth, and 
eighteenth centuries, and highly thought of by Hippo- 
crates, Galen, and Celsus, has been almost entirely 
abandoned by those of our own times, no one now 
ever thinking of bleeding in the radial artery, or 
opening the lingual, or those of the mastoid region, 
and very few of opening the temporal. Should this, 
however, be deemed proper, and should there be no 



298 BLOOD-LETTING. 

Other way of drawing blood from the part to be bene- 
fited by the operation, the anterior branch of the tem- 
poral should be selected, and not the main trunk. 

Operation. — The patient being seated, with the 
head supported, or else lieing down, we feel for the 
pulsation of the vessel, about fifteen lines in advance 
of, and above, the meatus auditorius externus, where 
the artery is almost without the temporal fascia, close 
under the skin, and well supported by bone behind. 
Then, with a lancet or bistoury, we cut the vessel in 
half transversely, either by cutting from the skin 
inwards, or, what is better, from within, outwards, as 
in Fig. 190, the instrument being previously intro- 
duced below the vessel. The artery should not be 
opened longitudinally, as the veins were, because the 
contraction of its muscular coat would tend to close the 
orifice, and stop the hemorrhage. As soon as the vessel 
is opened, the blood fiies in a jet, and may be either 
received directly into a basin, or else drawn off by a 
bent card or trough, as in the operation on the jugu- 
lar vein. Should the bleeding tend to stop before 
blood enough is taken, we should apply warm 
clothes to the part, wash out the clot, &c. ; but if 
enough has been taken, compress the artery below 
the puncture ; close the wound ; apply a compress, 
and fasten it either by a simple circular bandage of 
the vault of the cranium, or by the knotted bandage, 
shown before. We repeat, however, that the ope- 
ration, at the present day can hardly or ever be neces- 
sary, whilst the subsequent effects, from the forma- 
tion of aneurism, or the scar from the tieing of the 
vessel, are disagreeable and troublesome. 

LOCAL BLOOD-LETTING. 

The name of Local Bleeding is generally given to 
that in which the smaller vessels and those close to 
the diseased part, are opened. This is practised by 
means of Leeches, Cups, or Scarifications. 



BLOOD-LETTING. 299 

LEECHING. 

The Leech is an animal of the inter-vertebrated 
articulated family, Annelidese, that has been employed 
in medicine from almost time immemorial. This spe- 
cies, Hirudo Medicinalis, is an aquatic worm, with a 
compressed bodytapering towards each end, and ter- 
minating in circular flattened disks ; the hinder one be- 
ing the larger of the two. It swims with an undulating 
motion, and moves when out of the water by means 
of these disks or suckers: fastening itself first by one, 
and then by the other, and alternately stretching out 
and contracting its body. The mouth is placed in the 
centre of the anterior disk, and is furnished with three 
cartilaginous, lens-shaped jaws, lined at their edges 
with fine, sharp teeth, which meet so as to make a 
triangular incision in the flesh. It varies from two 
to three or four inches in its length, and inhabits most 
of the marshes and running streams of Europe, and 
many parts of the United States. 

Leeches afford the most effectual means of abstract- 
ing blood locally, as they are often applicable to parts 
which, from their situation or great tenderness, would 
not admit of the use of cups, and, in the case of in- 
fants, are always preferable to the latter. 

In order to apply them with ease to any part, care 
should be taken to free it, by washing, from all medica- 
ments; and by shaving off* all the hair or down on the 
skin. Jf the leech is very active or hungry, it will read- 
ily attach itself to the part when thus cleansed : but ge- 
nerally, it is necessary to moisten the surface with a lit- 
tle blood, or with milk, or with sugar and water, when 
the leech will readily leave the vessel containing it, 
and attach itself to the skin. If it is desirable to at- 
tach it to any one point, place it in a large quill or 
glass tube, and put this directly on the part ; when, as 
the animal cannot escape, it will readily attach itself. 
But when the part is not so circumscribed, it suffices 
to apply the edge of the cup holding them, just below 



300 BLOOD-LETTING. 

the point, and let them crawl on to it ; or place them 
under a tumbler, which confines their wandering, and 
causes them to attach themselves to the portion be- 
neath. (Fig. 192.) 

Where blood is wanted to induce them to bite, it 
may be readily obtained by tieing a string tightly 

Fis^. 192. 




round the extremity of the finger so as to render it 
turgid, and then lightly pricking it with a lancet ; the 
blood escapes in points, and may then be smeared 
on the body. This operation causes no pain, unless 
very often repeated on the same finger. 

Leeches continue to draw blood until they are 
gorged, when they drop off themselves ; but if it 
becomes necessary to remove them before they are 
thus filled, it should be done by washing them with a 
little salt and water, and not by pulling them off; as 
this is very apt to leave the teeth in the wound, be- 
sides being destructive to the leech. Six American 
leeches are calculated to draw one ounce of blood ; 
but as their bites frequently bleed as much as the ani- 
mal itself drew, this is but an approximation to the 
quantity. Some persons are in the habit of cutting 
off the tail of the leech, in order to cause it to con- 
tinue sucking for a long time, as the blood passes out 



BLOOD-LETTING. 301 

as fast as swallowed ; but it is a barbarous practice, 
and of course destructive to the utility of the animal. 
After the leech has come away, the bites continue to 
bleed, and this is often encouraged by the application 
of flannels, and cloths wrung out of hot water. But 
if we do not desire this extra amount of blood, cover 
their bites with a piece of linen moistened in sweet 
oil, or spread with fresh lard or cerate, to prevent its 
adherence to the wounds. Occasionally, it happens, 
in the case of children or weakly individuals, that the 
after bleeding is profuse and debilitating. To arrest 
it under these circumstances, it is only necessary to 
touch each bite with a sharp-pointed piece of lunar 
caustic, which will effect it almost immediately. A 
hot needle, stitches, &c., have been recommended, 
but the caustic is better, and more readily applied. 
In our large cities, where leeching is the peculiar 
business of a class of individuals, there is generally 
no difficulty in their employment ; but with the 
country practitioner it is different, as he must preserve 
and apply them himself, and this is thought to be very 
troublesome. Let it, how^ever, be recollected, that 
their application is sometimes a matter of absolute 
necessity ; that, as above shown, it is simple, and two 
of the objections to their use are removed. Their 
preservation is then the only point of difficulty. The 
leech, when gorged, remains inactive or unfit for use 
for several weeks, and is also liable to disease, by 
which numbers are lost. All that is necessary to 
guard against this, is perfect rest in a vessel of fresh 
water ; in a few weeks they will again be fit for use. 
The preservation of them by the following rules is 
easy, and always ensures a supply. Never squeeze 
them to cause them to disgorge, it brings on disease ; 
but place them in clean water, and change it frequently ; 
a glass jar answers every purpose. Then, in order 
to keep them in health and ready for use, place them 
in a large tub or trough, six or seven inches deep, in a 



302 BLOOD-LETTING. 

cool place, with a mixture of moss, turf, and frag- 
ments of wood at its bottom, with a few stones on this 
to keep it in its place. Place also, at one end, a piece 
of wood or earthenware filled with small holes and 
covered with a bed of moss, so that the leech may 
keep up^ its natural habits, and by drawing itself 
through the holes in the board or through the moss, 
sticks, or stones, free itself from the secretion of slime 
found on its body, which otherwise becomes the cause 
of disease. By changing the water occasionally, and 
keeping the trough or tub covered with a piece of 
muslin, in a cellar, any practitioner can always have 
a supply of these useful animals at his command. 
Let it be recollected, however, that those which 
have been used, are to be kept separate from the others 
for about two months, when they may be replaced in 
the trough till again called for. If, in applying 
leeches to any point of the body whence they might 
escape to internal parts, as about the anus, the mouth, 
&c., they should remain in these parts, they may be 
at once destroyed and ejected, by the free use of salt 
and water, either as an emetic or enema. But the 
fear, of any internal injury from them is groundless, 
as the heat and other peculiarities of the parts will at 
once destroy them. 

CUPPING. 

By the word Cup, is understood a little bell-glass, 
three to four inches high, from which we exhaust the 
air, so that when applied on the skin it may cause a 
congestion and rising of this membrane, from the 
pressure of the atmosphere upon the parts around the 
cup itself. These cups differ chiefly in the manner 
in which the air within them is exhausted ; some 
being slightly open at the top, and fitted to receive 
the end of a small air-pump : others being entirely 
closed and exhausted by the use of fire applied inter- 
nally in different ways. When the flesh is cut 



BLOOD-LETTING. 303 

after the application of the cup, the blood will flow 
freely from the incisions, when the exhausted cup 
is again placed over them, though it could not do so 
previously. This is termed cupping, or the applica- 
tion of wet cups, in contra-distinction to dry cupping, 
or that in which the cup is applied merely to irritate 
the part, without any scarification or drawing of blood. 
When we desire to exhaust a cup, it may be done 
either with the pump, by fitting it to the cup as pre- 
pared for it, applying the latter closely to the part, 
and then working the piston once or twice as in any 
ordinary pump : or by the use of fire to rarify the air 
within the cup itself. 

With this view, various means have been employed. 
It may be rarified either by the rapid insertion of a 
candle or little torch, and the instant application of 
the cup to the part ; or else, the fire may be placed 
in the cup and it at once put on the skin. To do 
this, some shake a little alcohol around the inside of 
the cup, pour out what flows readily, and inflame the 
little that adheres to the glass by a lighted piece of 
paper ; others introduce small balls of inflamed cot- 
ton saturated with alcohol ; others simply use pieces 
of burning paper ; but the two last cause unneces- 
sary pain, from burning the skin on which they fall. 
The best and neatest way of exhausting the cup, is 
the following. Cut several pieces of letter-paper 
slightly glazed, into strips about one inch and a-half 
wide. Wrap this round the end of the fore-finger, 
so that about one-third of its width shall project 
beyond the end of the finger, and having thus formed 
a little tube, tear off" the rest of the strip and twist 
the part projecting beyond the finger, so as to close 
up the tube, and form a little cap like a thimble. 
Dip the open end of this, lightly, into alcohol; a small 
portion will adhere to its glazed surface ; touch it in 
a candle ; throw it into the glass, and apply the latter 
at once to the part. The shape of the cone is such 



304 BLOOD-LETTING. 

that it will nearly always fall on its apex, or the 
twisted end, whilst the part wet with the alcohol, or 
the base, will stand uppermost and sufficiently far 
from the skin to prevent its being burnt. Having by 
either of these modes exhausted the cup, allow it 
to remain on the surface of the part till the skin 
under it has become turgid, when, if blood is to 
be taken, cut it by means of the Scarificator, and re- 
apply the cup as before ; removing it when filled or half 
filled with blood, and again applying it, if necessary. 
In order to remove the cup, introduce the nail of the 
fore-finger under its edge, and gently force the cup 
on to its side, so as to allow the air to enter. After 
wet cupping, the parts are to be cleansed, and co- 
vered with cerate or an oiled rag. 

If the regular cupping apparatus, as furnished by 
the cutler, is not at hand, we may perform the ope- 
ration very well by using wine-glasses or tumblers ; 
scarifying the parts if blood is to be taken, by rapid 
punctures of a thumb-lancet, bistoury, or sharp pen- 
knife. 



CUTANEOUS IRRITATIONS. 305 

CHAPTER II. 

OF CUTANEOUS IRRITATION. 

Another useful means of producing depletion, is by 
means of the cutaneous exhalents, or the establishment 
of serous and suppurative discharges by means of arti- 
ficial irritation. 

These inflammations are usually created on the 
surface of the body, with the view of relieving some 
internal inflammation or disorder, that is more dan- 
gerous to the life of the patient, than the one thus ex- 
cited, and when properly directed, are possessed of 
great power. Acting on the principle of revulsion, they 
relieve internal congestion and inflammation, by draw- 
ing the fluids to the surface : relieving internal conges- 
tion with as much certainty as any of the usual means 
of blood-letting ; whilst they are usually applicable to 
cases where the latter means would not be generally 
available, as in the chronic phlegmasiae, &c. 

To explain fully their modus operandi, or enter 
more in detail into the cases for their application, 
would lead to the consideration of points foreign to 
our present arrangement, and we must therefore con- 
fine our remarks to their production alone ; and first 

OF BLISTERS. 

The simplest drain that can be created on the sur- 
face of the body, is that arising from the formation of 
a Blister. This, which generally consists of an oint- 
ment of cantharides, creates only sufficient inflamma- 
tion to cause an effusion of serum under the cuticle, by 
which the epidermis is separated from the subjacent 
structure, and forms a cyst. On evacuating this cyst or 
20 



306 CUTANEOUS IRRITATIONS. 

vesicle,theslightulcerwhichisleftj usually heals kindly 
under the use of simple dressings, without much dis- 
charge. Butif it be desirable to make a more permanent 
impression, and continue the drain, instead of merely 
evacuating the fluid first secreted, we should seize the 
cuticle with a pair of forceps ; and either cut or tear it 
fromthe inflamed surface; then dress the excoriated por- 
tion with some stimulating ointment, as that of savine ; 
of cantharides; ofmezereon ; orcabbage,orbeetleaves ; 
or with any of the similar ointments of the Pharmaco- 
poeia. By these means, a permanent blister, as it is 
termed, may be kept up for six or eight weeks, though 
usually the discharge is continued with difficulty after 
this lapse of time. In such cases, the following 
plan will increase it and create an issue on the blis- 
tered surface. Take two or more peas, made of orris 
root, and bind them firmly to the part, through an 
opening made in the cerate which covers the rest of 
the sore, and continue the pressure until they ulcerate 
into the true skin ; when, by the use of any of the 
previous ointments, the discharge may be kept up for 
any period that may be desired. 

The blister, however, is not often employed in this 
way, as issues can be more readily created, and with less 
pain to the patient, by the means hereafter mentioned. 

When it is desirable to raise a blister in a very 
few minutes, as in cases of collapse, concussion, 
&c., the fly blister commonly employed will not an- 
swer, as it is too slow in its operation. Resort must 
therefore be had to something more active, such as 
compresses wrung out of scalding water and applied 
directly to the part ; taking care to prevent the escape 
of the liquid over surrounding parts. Or, a piece of 
thin soft paper saturated with spirits of turpentine, or 
alcohol, may be pressed firmly on the body ; set fire to, 
and allowed to burn for a few seconds. This raises a 
blister with great rapidity, but is extremely painful to the 
patient if consciousness is at all perfect. A plan recom- 



CUTANEOUS IRRITATIONS. 30^ 

mended by Sir Anthony Carlisle, was to lay a double 
folded piece of moistened linen upon the portion to be 
blistered, over which a flat cautery iron was passed, 
heated to a reddish-brown heat. 

But a neater plan than either of these will be found 
intheuseofGranville'sstrongrubefacientlotion,orpure 
Aqua Ammonia, applied directly to the spot by means of 
patent lint, or pieces of flannel saturated with it. This 
powerful remedy requires but a minute or two to raise 
a blister, if the ammonia is pure ; but like the hot 
water, requires caution, to prevent its flowing over 
surrounding parts. The best means of preventing 
this is to place the lint in a pill-box or wine-glass, 
and then press it against the skin : the edges of the 
box or glass circumscribing the action of the lotion. 
As the ointments before mentioned will tend to in- 
crease the effect of a blister, and augment the dis- 
charge after its production, so a mild soft poultice of 
any warm emollient substance, will generally diminish 
it when the inflammation runs too high. 

ISSUES, 

Are drains, thatare most generally caused by the action 
of some substance, which, by destroying the tissue, cre- 
ates a discharge in consequence of the efforts of nature 
to repair the damage. Two classes of agents possess 
this power : J st, Chemical Agents or Caustics, as com- 
monly designated, and 2d, Heat, or the actual or poten- 
tial cautery. Each of these, by destroying the organisa- 
tion of the skin, creates a dead mass called an eschar; 
this, being thrown off' by nature, leaves a cavity, 
which being filled with issue peas, or some irritating 
substance, keep it open and continue the discharge. 

Chemical Agents, or Caustics, are those most com- 
monly used. They may be employed in three forms, 
solid ; liquid ; and as paste. Of the solid kinds, 
we have the Potassa, or Kali Purum ; the Nitrate of 
Silver; the Bi-Chloride of Antimony, &c., all of which 



308 CUTANEOUS IRRITATIONS. 

act in the same manner : though the caustic potash is 
the one most generally preferred. 

In using this article, it is desirable to select such a 
spot for its application as will not involve any deep- 
seated important parts. Thus superficial joints ; arte- 
ries ; nerves; bones, &c., should be avoided, less the 
action of the caustic extend to them, and produce 
serious injury. Issues are therefore, most generally 
established in the fleshy part of the arm, or thigh, or 
on the back of the neck, or along the spine. If we 
choose the thigh, the depression which exists on its 
inner side, just above the knee will be found conve- 
nient ; if the arm, (and this is most common) take the 
space between the biceps and the deltoid, near the in- 
sertion of the latter. Then layingupon the spot selected, 
a piece of adhesive plaster, or kid spread with soap ce- 
rate, with a hole in its centre of the size desired for the 
issue, (generally about three lines in diameter), rub 
the integuments within this hole with a piece of the 
caustic potassa, till they become black, and repeat 
the operation each day, until an eschar is obtained of 
the desired depth. This usually should not be 
deeper than the integuments, lest it extend beneath 
the fascia, and produce subsequent trouble. Or, 
place in the opening of the plaster, a piece of 
potassa, about the size of a hemp-seed ; cover this 
with a strip of adhesive plaster, and apply over this 
a compress and bandage. After twelve hours, on re- 
moving the plaster, apply a warm poultice, in order 
to hasten the separation of the slough : which on 
coming away will leave a deep circular ulcer. This 
should then be filled by three or four peas made of 
Orris Root or Gentian, which by absorbing the mois- 
ture, swell, and distend the ulcer. Should they how- 
ever not prove sufficiently irritating, the ulcer may be 
dressed with Basilicon, Mezereon, or some other 
stimulating ointment. 

The daily dressing, subsequently used, must de- 



CUTANEOUS IRRITATIONS. 309 

pend upon circumstances. Thus fungous granulations 
must be repressed by the nitrate of silver ; suppuration 
kept up by moving the peas, and by the ointments just 
stated ; and too much inflammation prevented by the 
use of warm poultices, and mild cerates. The re- 
moval of the peas, and the use of simple dressings, 
will generally suffice to heal the sores. 

In order to protect the ulcer from accidental inju- 
ries, and also keep the patients' clothes from being 
soiled by the discharge, it is usual to cover the part 
with a small plate of tin, or some other light metal, 
moulded to its shape, and fastened by an elastic band 
which surrounds the limb. These little bandages are 
generally kept by the cutlers or druggists, and add 
much to the patient's comfort. 

When in the production of an issue, any apprehen- 
sion exists of the action of the caustic extending too 
deep, we may neutralise it by an appropriate article. 
Thus, washing the part with vinegar, will neutralise 
the caustic potash ; salt and water that of the nitrate 
of silver ; magnesia, or some other alkali, that of sul- 
phuric acid, &c. 

The formation of issues by incision, has so little to 
recommend it, that we shall pass it by. 

When other means cannot be had, iron heated in the 
fire may be substituted, for the caustics just mentioned. 
Heated to a white heat, and applied directly to the skin, 
the actual cautery immediately produces an eschar, 
which follows the same course asthat created by caustic. 
The fears of patients, and the greater convenience of 
other means, have thrown this out of general use. 

The Sulphuric, Nitric, and Hydrochloric Acids, are 
occasionally employed, when some objections exists 
to the means just stated. In order to use them, 
steep a small compress of patent lint fixed to the end 
of a small piece of wood, in the liquid, and apply it 
directly to the skin, guarding against the extension 
of the acid over surrounding parts. The esehar thus 



310 CUTANEOUS IRRITATIONS. 

made is then treated, as before stated. In the 
treatment of bites from rabid animals, the liquid 
caustics are preferable to the others, as they spread 
more rapidly ; but the wound should in these cases 
always be enlarged, previous to their use. 

OF SETONS. 

A Seton is one of our most powerful means of keep- 
ing up a cutaneous discharge. Strictly speaking, the 
seton itself is merely the band or substance employed 
to irritate the part ; though the same name is given to 
the operation by which this band is introduced be- 
neath the skin. Its use is now very generally con- 
fined to the back of the neck, though it may be also 
applied to certain other parts, as the fleshy part of the 
thigh, or arm ; but for these points, issues are gene- 
rally preferred. 

In order to apply a seton, we require a sharp cut- 
ting instrument to make an opening through the in- 
teguments : and some strip, which, when introduced, 
will, by its irritation, keep up a suppuration from the 
part. For the insertion of the strip we have two instru- 
ments, Boyer's Seton-Needle, and a common straight 
bistoury and eyed probe. 

The first consists of a flat steel blade, about five 
inches long : six lines wide, and perforated at one end 
with a hole large enough to receive the strip to be 
introduced ; the other end is sharp, and sloping to a 
point like a thumb lancet. To introduce the seton 
with this, first fasten the substance to be used, in the 
eye of the needle, and then seizing a portion of the 
integuments of the required width, between the fore- 
finger and thumb of one hand, raise it up from the 
parts below, and transfix its base by forcing the nee- 
dle through : drawing it and the seton out on the 
opposite side to that on which it entered, so as to 
leave the seton in the wound. After which, its ends 
should be fastened down to the part by a little piece 



CUTANEOUS IRRITATIONS. 



311 



of adhesive plaster, and the whole covered for the first 
three days by a warm poultice, till suppuration com- 
mences ; when a simple dressing is all that is requisite. 
The objections which we have to this method 
are, that the seton- needle is not always at hand, that 
the fastening of the seton in its eye is apt to make a 
thick mass, which passes through the opening with 
difficulty, and that it is hard to hold the point of the 
needle, when wet with blood, so as to draw it through. 
We thereforepreferthestraightbistouryand eyed probe. 
To use this, fix the seton by a thread to the eyed 

Fig 193. 




probe ; seize the integuments as before ; cut them with 
the bistoury, and before removing it, introduce the 
point of the probe from the opposite side, and with- 
drawing it and the bistoury at the same time, insert 
the seton in its place (Fig. 193). 

In respect to the substance of the seton, there is 
much diversity of opinion. But let the substance be 
what it will, it must always be well anointed with 



312 CUTANEOUS IRRITATIONS. 

ointment previous to its introduction, and also pre- 
vious to any movement of it through the wound in 
subsequent dressings, in order to facilitate its pro- 
gress or increase its action. For the first three days 
the poultice is stained by blood, or slight oozings ; 
but afterwards by pus. When suppuration has freely 
commenced, the substance of the seton becomes 
charged with matter, which, if allowed to remain, ren- 
ders it very offensive. At each daily dressing, therefore, 
the seton should be drawn through the wound till this 
soiled part is free, when it is to be cut off, and the ends 
fastened down and dressed as before with simple dres- 
sings ; the whole being confined by a circular bandage 
of the neck, as at Fig. 33, or by a sling, as at Fig. 
85. But as the seton by this operation is soon cut up, 
it will be necessary to prepare for the introduction of a 
new one. This is readily accomplished by attaching 
it by a few stitches to the old one ; anointing it well, 
and drawing this into its place, as the old one is re- 
moved. A skein of saddler's silk, or a piece of silk 
braid, is the article most frequently employed ; but 
where we can obtain a strip of gum-elastic, or 
braid or tape coated with it, they will be found to 
be much more cleanly than the silk. For the cases 
requiring the use of the seton, and for the period of 
its duration, we must refer to other works. 

OF MOXA. 
This is the name given to little rolls of inflammable 
matter, intended to cause eschars and subsequent 
issues, by being allowed to burn upon the integuments 
until they cause its destruction. These are made of 
various substances, as cotton, lint, tow, &c., soaked 
in a saturated solution of nitre ; dried and then wrap- 
ped up in little bags ; or, rolls of silk, or muslin, 
sewed together at the sides, formed into rolls and 
coated with gum ; or we may use the common 
punk, as found in the shops of the tobacconist, cut 



CUTANEOUS IRRITATIONS. 



313 



into pieces about one inch long. The application of 
any of these cylinders is very simple. Having chosen 
a spot where the subjacent parts of importance are 
not likely to be injured by the extension of the inflam- 
mation, place upon it a piece of moistened cloth, 
with a hole in its centre large enough to receive the 
moxa. This cloth is intended to preserve the sur- 
rounding parts from the sparks which sometimes 
escape. Next see that the end of the moxa is applied 
to the body flatly, so that it may fit itself accurately 

Fis'. 194. 




to the surface, and moisten it with a little gum to 
make it adhere ; or else hold it firmly on the part, 
by a pair of forceps, or a porte-moxa or metallic ring, 
as in Fig. 194. Having now lighted one end of the 
cylinder, keep up the combustion by the breath, or 
by a pair of bellows ; the latter being necessary where 
the smoke irritates the bronchia too much. In its 



314 CUTANEOUS IRRITATIONS. 

burning, the patient first feels a gentle heat, which 
gradually increases, until, as the fire approaches the 
part, the pain for the moment becomes excruciating, 
and then destroys entirely the vitality of the skin. The 
eschar thusformed is afterwards treated like the eschar 
formed by the caustic issue ; the subsequent treat- 
ment being similar to what has been there said. 



X 



PUNCTURES. 315 



CHAPTER III. 



OF PUNCTURES. 

In various cases of accumulation of liquids and 
gases within the cavities of the body, it is found ne- 
cessary to evacuate them by a class of operations 
which divide the tissues in a manner somewhat 
analogous to incisions, yet differing from them in the 
instruments employed, and in the method of using 
them. 

In these cases, perforations are made by sharp- 
pointed instruments of different kinds, which are 
pressed or pushed beneath the skin, by a sudden 
movement, so as to divide the tissues by pressure, 
instead of by the saw-like action of the knife or bistoury. 
Under this head we shall therefore treat of those ope- 
rations requiring the instruments and movements re- 
ferred to ; excepting^such as have been already spoken 
of, under another head. 

OF ACUPUNCTURATION. 

The simplest puncture, that can be termed an 
operation, is that made by the introduction of 
needles under the skin. With the exception of their 
employment in exploring doubtful tumours, &c., their 
use is mainly confined to what is known as Acupunc- 
turation. This consists in making a number of small 
punctures in the skin by means of needles of gold, 
silver, platina, or steel, shaped as in Fig. 195, and 
introduced into the part by rapidly rotating them be- 
tween the fingers. Marked benefit in certain cases, 
was said to have been derived from their use, and as 
they caused but little pain, the operation was at one 



316 PUNCTURES. 

time quite popular. Employed from an early period 
by the Japaneese, and others, in order to relieve va- 
rious internal disorders, so rapid was their action, that 
miraculous powers were wildly ascribed to them. 

Fig. 195. 




A 

Subsequent investigationshavenothowever, supported 
this, and the want of success drove the operation 
therefore into comparative disuse. Without, discuss- 
ing the advantages of the operation, we shall, therefore, 
no w simply detail the method of its performance. The 
place being chosen, take hold of the head of the 
needle, or of the handle into which it is sometimes 
inserted, with the thumb and fore-finger of the right 
hand, supporting its stem with the thumb and fore- 
finger of the left. Press it, with a rotary motion, to 
the depth of several inches if requisite to reach the 
seat of pain, and leaving it there, introduce several 
others at slight distances apart. If the needles are 
sharp, and rotated rapidly, the pain of their introduction 
is very slight, and in certain neuralgic cases especially, 
their use is even said to be agreeable to the patient. 
But without trusting to the effects of imagina- 
tion, we should liave more confidence in another 
method of treating such patients, which has an addi- 
tional recommendation in the employment of a nar- 
cotic. This consists in making numerous punctures 
with these needles, or with a sharp-pointed lancet, so 
as barely to draw blood, and then washing the part 
with a strong solution of sulphate of morphia. The ap- 
plication of the anodyne thus directly to the seat of pain, 



PUNCTURES. 317 

is said to relieve it very quickly, and must, we think, 
prove serviceable : although we have never had occa- 
sion so to use it. 

ELECTRO-PUNCTURE. 

The advances lately made in the science of gal- 
vanism and electricity, has again brought into use 
the operation of electro-puncture. This operation is 
the same as the preceding, so far as the introduction 
of the needles : but differs subsequently, in its being 
aided by the action of the electric fluid directly on the 
diseased part. In using this fluid, we must of course be 
governed by its general laws, and if we wish to pro- 
duce only slight shocks, cause the spark of the appa- 
ratus employed, to fall indirectly on the head of the 
needle shaped as at A, Fig. 195 ; but if a more severe 
action is desired, keep up a continual current through 
the needle, by direct contact with it, of the poles of 
the machine. The Electro-Magnetic apparatus is ap- 
plied in the same way as the electrical machine, and 
it matters probably but little, in what way the fluid is 
applied to the needles, provided the circuit of the 
current is continued throughout them. The cases in 
which it is adapted, and their probable results, may 
be found fully treated of in most of our Dictionaries, 
under this head. 

VACCINATION. 

Nothing need be said at the present day as to the 
advantages of this operation. Trifling as is its per- 
formance, its proper effect, however, depends in a 
great measure on its correctness ; and passing by, 
therefore, much that has been stated in regard to 
the shape, size, and number of the punctures, we shall 
merely mention the plan that we pursue in operating, 
and have generally found successful. 

Scrape slightly the epidermis on the spot selected, 



318 



PUNCTURES. 



with a moderately dull thumb lancet, until it removes a 
small amount of the cuticle, in the shape of a light dust. 
As soon as the skin underneath becomes pink, or shows 
very minute points of blood, place a drop of the liquid 
from the pustule, or from the dried scab, softened and 
made liquid by water, upon it, and press it beneath the 
skin by three or four slight punctures with the point 
of the lancet (Fig. 196), just deep enough to tint the 

Fig. 196. 




matter with the blood, but not so as to make the part 
bleed freely ; then keep the arm exposed to the air until 
the matter dries or hardens. In order to guard 
against subsequent irritation, tie up the child's sleeve 
to the shoulder, or cover the spot operated on with a 
piece of fine linen. 

The choice of the lancet — the point of the arm to 
be selected — the age of the patient, &c., have all 
received much minute consideration in the different 
treatises on vaccination, which we think it is useless 
here to refer to. Suffice it to say, that the sooner a 
child is vaccinated after one or two months, the bet- 
ter ; that the point of insertion of the deltoid mus- 



PUNCTURES. 319 

muscle on that arm which is furthest from the nurse 
when the child is carried, is generally the most con- 
venient place for the operation : and that a plan that 
answers well, is that just stated. The necessity for ob- 
taining good matter , renders the preservation of it a point 
of considerable importance, and various plans have 
been employed for this object and strenuously advo- 
cated by their especial supporters. Jenner received 
a drop of the matter, fresh from the pock, in a little 
hollow of a square piece of glass, which was then 
covered by another piece, and both luted together to 
keep out the air. Bretonneau, Friard, &c., of the 
French surgeons, employed glass tubes of a fine cali- 
bre, with the same view ; but in this section of the 
United States, the matter is generally preserved in 
the dried state, and transmitted from one point of the 
country to another by mail : being pulverised and 
moistened w^ith a drop of warm w^ater when required 
for use. A simple plan of preserving the dried scab 
free from the air, is to make a little hollow in a cake 
of bees-w^ax : then soften the surface of this and ano- 
ther cake by heat, or scrape them perfectly smooth, 
and after placing the scab in the hole made for its 
reception, press the two cakes together, so as to form 
an air-tight box. We have vaccinated successfully 
in several instances, with a scab nearly four months 
old, preserved in this manner. 

The appearance of the arm, on the different days 
after the operation, is a matter of vital importance in 
forming an opinion of the results of the case ; and as 
an error of judgment here, by giving the patient a 
false security might lead to sad consequences, we 
shall not pretend to enter fully into its appearance, 
but refer the reader to the larger works. 

Figure 197 is an attempt to represent the proper 
appearance of the arm at the third, seventh, eighth, 
ninth, eleventh and twelfth days after the operation. 
But it does so very imperfectly, owing to the absence 



320 PUNCTURES. 

of color. Those unacquainted with it must, there- 

Fig. 197. 






•^li^^-' 



fore, consult some of the more finished plates on this 
subject, and only look to the cut, as an outline. 

PERFORATION OF THE LOBE OF THE EAR. 

The fashion of the day, and the taste of a numerous 
portion of the community, leading them to the use 
of rings in the lobe of the ear, it may occasionally 
happen that the practitioner will be called on to intro- 
duce them : although generally, this is the business 
of others. As serious inconveniences have, however, 
frequently resulted from this arrangement, involving 
materially the comfort and health of the individual, it 
would perhaps be better were the profession to have 
a closer supervision of this little operation than is now 
generally the case. 



PUNCTURES. 



321 



The perforation of the lobe of the ear may be ac- 
complished either by a large needle ; by a small 
trocar and canula, like that used in hydrocele ; or by 
a small punch similar to that employed by saddlers. 

In either case, the lobe should be steadily pinched 
between the thumb and fore-finger for a few minutes 
previous to the operation, in order to diminish its 
sensibility ; then placing a piece of cork beneath the 
point to be perforated, force the needle or punch 
rapidly through the flesh, so as to make a free open- 
ing (Fig. 198). Immediately on withdrawing the 

Fig. 198. 




instrument, introduce a waxed thread, or a fine leaden 
ligature, or a piece of catgut, and move it daily 
through the perforation, in order to prevent its sides 
from adhering. Not unfrequently this movement 
produces so much irritation and discharge, as to con- 
stitute a regular seton, and is occasionally employed 
by the lower orders of society with this view. But 
generally, after the lapse of ten days, the skin 
on the sides of the wound heals, and an opening is 
left through which the ear-ring is afterwards passed. 
21 



322 PUNCTURES. 

We have several times known instances when the 
needle was used, where the union of the w^ound has 
required the repetition of the operation : the punch 
by removing the piece, effectually prevents this, and 
is, therefore, the preferable instrument. 

The point selected for the perforation, should always 
be sufficiently far from the extremity of the lobe, to pre- 
vent the weight of the ring, or accidental catching of it 
by children, from tearing it out. When this happens, 
a marked deformity is produced, which, if the wound 
is not united soon after its production, w^ill require 
an operation similar to that for hare-lip. 

PUNCTURE OF THE MEMBRANE OF THE 
TYMPANUM, 

And that of the mastoid cells, might next be treated of; 
but they involve so many points of practice, as to 
exclude them, at present, from our consideration. 

PARACENTESIS ABDOMINIS, 
Or Tapping^ becomes necessary, whenever (owing to 
some general disease) a large amount of serum accu- 
mulates in the peritoneal cavity of the abdomen, and 
by its distension impedes the respiration of the pa- 
tient, or is otherwise productive of harm. As usually 
performed, a trocar and canula are employed, which, 
perforating the abdominal parietes, give exit to the 
fluid contained within it. The spot generally selected for 
the puncture, is in or near the linea alba, or two inches 
below the umbilicus: because we are here free from all 
danger of wounding important parts. The spot being 
chosen, place a broad band, slit at its extremities, into 
six tails, (like the bandage of Galen, p. Ill,) around 
the abdomen, with the tails crossed on the back of the 
patient, and direct two assistants to tighten it gra- 
dually as the fluid escapes, in order to force out the 
serum, and at the same time prevent the patient's 
fainting from the sudden loss of pressure on the 
abdominal vessels. The bladder being emptied. 



PUNCTURES. 323 

the surgeon should next remove a small piece of the 
bandage, immediately over the point which he 
proposes to perforate, and holding the trocar, as 
represented in Figure 199, suddenly force it and 
the canula into the abdomen. Holding the canula 

Fis-. 199. 




in its position, and withdrawing the trocar, the 
fluid immediately escapes through the canula into 
the basin held in front of the patient. A tub or 
bucket should always be at hand, into which it may 
be emptied when required, as the amount of fluid is 
sometimes very large. After the evacuation of the 
liquid, the wound is to be closed by a strip of adhe- 
sive plaster ; the bandage tied tightly in its. place, 
and the patient put to bed and kept on strict diet. 
But as peritonitis frequently results from this ope- 
ration, simple as it appears, the young practi- 
tioner is advised to be careful of his patient for 
several days afterwards, and especially cautious of 
his diagnosis in the case of females. As the cause 
of the disease is not affected by the operation, it 
generally happens that its repetition is almost inde- 
finite, though the subsequent performance does 
not differ in any respect from the one just de- 
scribed. The kind of trocar used is somewhat a 
matter of taste; but we always prefer the flat instru- 
ment, as creating less pain and causing a smaller 
wound than that which is round. In either case, par- 
ticular attention should be given to cleansing the 



324 PUNCTURES. 

trocars after the operation, as the rusting of the 
trocar in the canula frequently renders it difficult to 
withdraw the former. In one instance that came 
under our notice, the instrument was driven into the 
abdomen^ and the operator obliged to withdraw it, 
owing to his inability to free the one from the 
other. A little oil after using it, would have saved 
him this mortification. 

PUNCTURE OF HYDROCELE. 

The evacuation of serum from the Tunica Vagi- 
nalis Testis, is generally produced by means similar 
to those just detailed. The scrotum being firmly 
squeezed in the left hand of the operator, a small 
trocar and canula are forced into it, and directed ob- 
liquely upwards, in order to avoid injuring the tes- 
ticle ; this being generally found at the posterior infe- 
rior portion of the swelling. Should a trocar not be 
at hand, a thumb lancet may be used in the same 
way, and the wound kept open by a probe until the 
fluid is evacuated. But the trocar is far preferable, 
as it avoids the risk resulting from the escape of the 
liquid into the cellular tissue of the scrotum. The 
operation is, however, merely palliative, unless in- 
flammation of the serous cavity be afterwards induced. 

The Diagnosis of the disease concerned in these opera- 
tions is, we think, decidedly the most important point 
connected with them, and we would, therefore, 
invite attention to the means usually regarded as 
effectual in deciding it. In Ascites the previous his- 
tory of the case : the probability of pregnancy : or 
disorder of the liver, or heart, or kidney, or some other 
organ, will do much towards preventing mistakes. 
Yet even then, nothing but the absolute certainty of the 
effusion should render the operation justifiable. This 
may generally be proved beyond a doubt by placing 



PUNCTURES. 325 

one hand, fully expanded, upon one side of the belly, 
and then tapping lightly and quickly, with the points 
of the fingers of the other hand, on the opposite side. 
The force of the tap acting upon the fluid, will drive 
it to the opposite hand, and a distinct succussion or 
fluctuation be perceived under the one first extended 
on the abdomen. Should flatus be present, the tym- 
panitic resonance will indicate it, but there will be 
no sensation given to the hand by tapping the fin- 
gers on the side of the belly, as is always felt, if there 
be a sufficient amount of eflfusion to justify its evacua- 
tion. 

In Hydrocele, the most certain test of its existence 
is the following : Place the patient in a dark room, 
and then grasping the scrotum tightly, hold a lighted 
candle as near it as possible, without burning the 
patient. The liquid, if serum, will be perfectly trans- 
parent, and the testicle be seen as a dark mass, 
wherever it may be situated. This, will also be found 
a most useful test in diagnosticating hernia; sarcocele, 
or haematocele ; as the appearances of these are en- 
tirely different from that of hydrocele. 

RANULA, 

Or an accumulation of the salivary secretion in the 
sublingual ducts, requires an operation not only to re- 
move the fluid, but also to guard against the perma- 
nent closure of the opening made. This operation 
may be performed either with a thumb lancet, bistoury, 
or trocar, by elevating the patient's tongue, and push- 
ing the instrument directly into the tumour, parallel 
with the alveolar processes of the lower jaw. After the 
escape of its contents, it is then necessary to introduce 
something into the wound to keep it open. A simple 
instrument, for this purpose, (analogous to that of 
Dupuytren,) may be made by bending a piece of fine 
stiff* wire, two inches long, upon itself, so as to give 
it the shape of the letter V, and introducing the 



326 PUNCTURES. 

point into the cyst ; the elasticity of the wire being 
sufficient to dilate the opening until the chance of 
its union is past ; the patient being cautioned not to 
derange it. 

Breschet and others have thought that Ranula in- 
stead of being an obstruction of the duct, was caused 
by regular cysts. Be this as it may, the operation of 
excision of a portion of the surface usually suffices 
for their cure. 

OF SALIVARY CONCRETIONS. 

Depositions of earthy matter, chiefly phosphate 
of lime, are occasionally found in the openings of 
the salivary ducts, and when of any size, give rise 
to considerable inconvenience by impeding the enun- 
ciation and deglutition of the patient. When large, 
they may be readily removed by an incision on 
the parietes of the duct, and seizing them with for- 
ceps ; but when small, they are not so easily caught, 
as they slip back in the line of the duct. Under 
these circumstances, it has been recommended to 
cause the patient to chew any substance likely to 
excite the flow of saliva, after making a slight inci- 
sion ; the escape of the fluid generally bringing 
away the concretion. A figure of a salivary concre- 
tion, taken from Liston, is represented in the cut, 
and gives a good idea of their 
Fi^.2(i0, shape and size, though occa- 

sionally much larger. We have 
seen one which was so large as 
to fill up the space beneath the 
tongue, and resembles a large 
Ranula, except in the colour 
and consistence of the tumour. 

PUNCTURING OF ABSCESSES. 

The existence of pus under certain tissues, espe- 
cially under fascia, &C.5 renders its detection and 




PUNCTURES. 327 

early evacuation often a matter of considerable im- 
portance, in order to prevent its extension, and the 
consequent injury of surrounding parts. To the young 
surgeon, and often to those more advanced, few things 
are more deceptive, and occasion greater doubt as to 
the evidences of its existence, than these accumula- 
tions of matter. In examining a deep-seated part 
where pus is suspected to exist, even when care is 
taken, deception is apt to follow, unless pressure is 
made in the proper manner, as may be readily proved 
by the following simple experiment : Place the mus- 
cles of the thigh or leg in a state of relaxation, and 
press on any given point with two fingers of each 
h?ind, aUernately ; the sensation of fluctuation will be 
so distinct as to deceive any one unacquainted with 
the fact. Now, if under the suspicion of the existence 
of pus, pressure is made in the same way, an opera- 
tion for its evacuation might be urged, and the prac- 
titioner mortified in not finding the matter, of whose 
existence he felt so certain. 

Previous then to opening an abscess, render the 
fluctuation apparent by the following means : Press 
one or two fingers of one hand, firmly on the side of 
the point suspected, and keep them thus firmly fixed : 
whilst pressure is first made and then removed, by the 
application of the fingers of the other hand. If mat- 
ter exists, it will be forced against the fingers first 
applied, and the fluctuation rendered certain ; whilst, 
if it does not, the deceptive movement of the muscles 
of the part, first referred to, will be prevented. 

The existence of pus being positively established, 
its evacuation by puncture may be performed either 
with a sharp-pointed bistoury, or abscess lancet, by 
plunging it into the collection at right angles to its 
surface, and enlarging the opening by cutting out- 
wards and upwards ; or by introducing it perpen- 
dicularly to the surface until it enters the cavity (as 
shown by the want of resistance,) and then cutting 



328 PUNCTURES. 

outwards. Or, if the abscess is superficial, the 
bistoury may be thrust through it, and a free open- 
ing made simply by elevating the handle, and cutting 
from within outwards, as in Fig. 201. The subsequent 
treatment will depend upon the circumstances of the 
case. 

Of the use of Potassa for the evacuation of abscesses, 
we have nothing to say ; preferring the knife for this 
purpose. 

Fig-. 201. 




In large deep-seated abscesses or tumors, the con- 
tents of which are doubtful, the introduction of a 
grooved needle, or one somewhat coarser than those 
used in Acupuncturation, will frequently enable us to 
decide on their contents, and save much trouble to 
both patient and practitioner. 



ARRESTING HEMORRHAGE. 329 



CHAPTER IV. 

OPERA.TIONS FOR ARRESTING HEMOR- 
RHAGE. 

The existence of hemorrhage generally creates so 
much alarm, and actually involves so much danger, 
that little need be here said, in reference to the im- 
portance of a proper plan of treatment : as common 
sense alone dictates the necessity of arresting it at 
an early period, lest its amount debilitate or affect the 
life of the patient. 

Of the various operations required for this purpose, 
the simplest is undoubtedly that of Pressure, which 
in common with the other means required, we shall 
treat of, without any reference to the physiology of 
their action. 

PRESSURE FOR ARRESTING HEMORRHAGE, 

May be applied, either by the Fingers ; by Compresses 
and Bandages ; by the Spanish Windlass ; or by the 
Tourniquet. 

In the first, the application of the force must de- 
pend much upon the position of the part, and the 
circumstances of the case ; and as the hemorrhage 
from the arteries is that which is of the most import- 
ance, we shall confine our remarks to it. When 
blood escapes from an artery, it does so in jets, cor- 
responding with the pulsations of the heart, and is of 
a bright red color. This jet generally shows the posi- 
tion of the injured vessel, and the origin of the he- 
morrhage, if superficially seated. The introduction 
of the point of the finger to the bleeding vessel, and 
pressure at that point, will therefore generally suffice 



330 OPERATIONS FOR 

to arrest it, until more powerful means can be ob- 
tained. But if the wounded vessel is deep-seated, 
and the point wounded cannot be thus seized on, 
pressure must be made upon the artery, at some point 
of its course, above the seat of injury : that is between 
the heart and the wound. 

This pressure may be made either with the points 
of three or four fingers, closely placed together ; or by 
the thumb. If the Fingers are used, place their points 
close together in the course of the artery, and seize 
the opposite side of the limb with the thumb, so as to 
steady them, (Fig. 202) or place the point of the 

Fig. 202. 




thumb upon the vessel, and the fingers on the oppo- 
site side of the limb, and when the pressure fatigues 
the thumb, place that of the other hand on top of the 
first, and thus relieve it (Fig. 203). But even when 
possessed of great powers of endurance, few persons 
can continue this sort of effort except for a few 
minutes, and these means are therefore only available 
for a limited time, as the fatigue soon requires a re- 
lease of the hands employed. 



ARRESTING HEMORRHAGE. 



331 



When it is absolutely necessary to employ pressure, 
as upon the Sub-Clavian and Iliac arteries, a large key, 
wrapped around with bandage, so as to prevent the 
handle from injuring the soft parts, will prove an ex- 
cellent instrument, and far preferable to the fingers 

Fig. 203. 




or thumb, not only on account of the adaptation of its 
shape to the part, but also because the pressure may 
thus be continued for a greater length of time. 

The French surgeons frequently employ pressure 
for arresting the circulation in a limb during amputa- 
tions ; but as its success depends upon the strength and 
address of the assistant, we would not advise its em- 
ployment as a general thing, where a tourniquet can 
be had. 

The use of compresses and bandages for this pur- 
pose, has been already referred to (page 31), and 
require no addition to what was there mentioned. 

THE SPANISH WINDLASS, 

Is an excellent, every-day instrument, of considerable 
power, and yet of great simplicity ; it may be made 



332 



OPERATIONS FOR 



on the spur of the moment, by twisting a pocket-hand- 
kerchief, and tying a knot in its middle. Then plac- 
ing the knot over the vessel, tie the ends of the hand- 
kerhief loosely on the opposite side of the limb : and 



Fig. 204. 




introducing a stick into the loop formed by the ends, 
twist the handkerchief by turning the stick as repre- 
sented in the cut, (Fig. 204). 



THE TOURNIQUET OF PETIT, 

Which is the one most generally employed in the 
United States, should be applied as follows : Place 
a compress over the vessel, and surround the limb 
with two or three turns of a bandage, so as to bind 
the compress on the part, and thus protect the skin 
from being chafed by the strap of the instrument. 
Next place the plates, closely screwed together, 
directly over the compress, and strap it firmly in its 
place, without any reference to the position of the 
buckle, as the plates, and not the buckle, are to make 
the pressure. On screwing the instrument, the com- 
press will be firmly forced on the vessel, and the 
circulation arrested, in consequence of the separation 
of the plates by the action of the screw : the lower part 
of this being made to bear directly on the compress. 
Many surgeons, however, advise different plans from 



ARRESTING HEMORRHAGE. 333 

the above, the advantages of each of which they ad- 
vocate ; but the one just stated, embraces, we think, 
the intention of the inventor, and is free from the 
objection of many of the accidents likely to arise from 
the use of the instrument, in other ways. In opera- 

Fig. 205. 




tions, the limb should be elevated a few minutes pre- 
vious to the application of the tourniquet, in order to 
empty the veins, and save the loss of blood which 
otherwise follows the division of the vessels. All 
these means of arresting hemorrhage, are however, 
temporary; and we caution the young practitioner 
against relying on them, for more than an hour, or an 
hour and a-half : as the arrest of the circulation in the 
limb for a greater length of time, might in some cases 
produce mortification. We once saw a thigh ampu- 
tated on account of a slight incised wound of the 
knee : which opening one of the small articular arteries 
of the part, gave rise to hemorrhage. This, an igno- 
rant practitioner attempted to arrest by the use of a 
tourniquet applied to the femoral artery, and kept 
there, notwithstanding the sufferings of the patient, 



334 OPERATIONS FOR 

for two days ; when mortification became apparent. 
Whenever, therefore, it is necessary to arrest the flow of 
blood more permanently, the ligature or torsion must 
be resorted to. 

LIGATURES, 

Act by direct closure of the vessel ; and are made of 
various substances, according to the taste of the sur- 
geon. Provided they are not so fine as to divide the 
coats of the artery too rapidly, we believe that it 
matters little what material is employed ; silk, home- 
spun thread, shoemaker's thread, kid, catgut, lead, 
&c., rolled more or less round, will all answer the 
purpose. In order to apply the ligature to a divided 
vessel, it is necessary to pick it out from the surround- 
ing parts, and this may be effected either by the tena- 
culum or forceps. 

The Tenaculum being the instrument generally pre- 
ferred, is used by sticking its point into the vessel, 
and drawing it out from the wound, until the loop of 
the ligature can be tied over it. But if Forceps are 
preferred, seize the vessel with a pair of Liston's, 
which we think decidedly the best for this pur- 
pose, and draw out the artery as before. These 
forceps (Fig. 206), being fitted with teeth, and a spring 

Fi^. 206. 




in the handle, w^ill retain their hold of the vessel, 
even when allowed to hang, and thus enable the sur- 
geon to place a ligature without the aid of an assist- 
ant. The firmness of their hold has given them the 
nick-name of bull-dogs. 



ARRESTING HEMORRHAGE. 335 

In tieing a ligature, one loop is usually thrown 
around the extremity of the vessel, beneath the in- 
strument and tied. Then forming a second knot on 
the first tie, draw it tight, by using the thumbs in 
the way that a shoemaker draws his wax-end. 

Various knots have been recommended, as least 
likely to slip ; among the most common of which are 
those known as the surgeon's and the sailor's knot. 

THE SURGEON'S KNOT, 

Is made by passing either end of the ligature, twice 
around the other, and drawing it tight. The figure 




(207), represents the left end, or that taken from the 
right hand, turned twice around the other, in order to 
form the knot, but not drawn tight. These turns, 
however, form a flat knot, like a figure of 8, and do 
not compress the vessel as tightly as the sailor's knot. 
It is therefore but little used at present. 

THE SAILOR'S KNOT, 

Like the clove hitch, is one, that when drawn tight, will 
hold very firmly, all that is included within it. Owing 
also to the firm compression that it exercises on the 
vessel, it is the one most frequently employed in tie- 
ing ligatures, as it divides the internal and middle 
coats more rapidly. In order to form it, tie a knot as 




336 OPERATIONS FOR 

in the lower loop of Fig. 208, and then a second or 

third on top of that, draw- 
Fig'. 208. ing each knot firmly with 

the thumb as just referred 
to. Or, if the figure is not 
sufficiently plain, practise 
it as follows : take a turn 
of the ligature around the 
finger, passing from left 
to right, and bringing the 
right hand end around 
the left ; knot it firmly ; then bringing the left hand 
end around the right, reverse the first turns, and 
again knot it firmly. Should any doubt exist as to 
its firmness, a third or fourth knot may be formed 
on top of these, by the same turns : going first from 
left to right, then from right to left ; and afterwards 
continuing the turns from right to left, as required. 

In the application of ligatures to arteries in exten- 
sive wounds, one end should generally be cut off within 
a quarter of an inch of the knot, and the other brought 
out of an angle of the wound, in order to facilitate the 
removal. Occasionally, both ends are cut off, and the 
knot left to come away with the discharge ; but the 
first plan is preferable for many reasons. 

TORSION, 
Or twisting of the artery, arrests hemorrhage on the 
same principles as the ligature, so far as the coats of 
the vessel are involved : — viz. by lacerating the inter- 
nal and middle coat. It is performed by seizing the 
end of the vessel with a pair of forceps which close 
with a catch, and then rotating the instrument in the 
fingers, twist the artery upon itself. Although a favour- 
ite method with the French surgeons, and answering 
tolerably well for small vessels during extensive oper- 
ations (as it saves the time required for the application 
of ligatures), yet it cannot be permanently relied on ; 



ARRESTING HEMORRHAGE. 337 

and we would not employ it except in the cases referred 
to, where ligatures may be subsequently applied if de- 
sired : as secondary hemorrhage not unfrequently re- 
sults from it. 

But if the hemorrhage comes from a deep- 
seated vessel, it is frequently necessary to cut down 
in its course, and throw a ligature by tenacula and 
other instruments, around the artery, above the seat 
of injury. These operations are, however, gene- 
rally so important, and depend so much upon the 
anatomical knowledge of the operator, that they would 
be misplaced if treated of here. 

Besides that just considered, hemorrhage not unfre- 
quently occurs from different cavities of the body : 
where, instead of one main vessel being the source, 
the blood comes from numerous small ones by a gene- 
ral oosing. Under these circumstances, styptics, or the 
introduction of foreign bodies into the part, in order 
either to make pressure or assist the formation of the 
clot, will be found necessary to arrest it. 

Among Styptics, the direct application of the Ni- 
trate of Silver to the bleeding surface, will, we think, 
prove the best, or, we may use the Tinctura Ferri Chlo- 
ridi, or Powdered Galls, or Sulphate of Iron, or Cop- 
per, or Zinc, or Acetate of Lead, or Alum, or Agaric, 
or Powdered Ice, or the Potential Cautery, &c., &c. 

But where the bleeding cannot be thus stopped, 
plugging up the part in order to assist in the formation 
of a clot, becomes necessary. 

PLUGGING OF THE NOSTRILS, 
In order to arrest excessive hemorrhage from this organ, 
requires the introduction of a foreign body not only 
into the nose in front, but also into the posterior nares. 
This may be best accomplished by Bellocque's canula 
armed with its stylet and ligatures, as follows : Pass 
the point of the canula along the floor of the nostril 
till it reaches the soft palate. Then pushing forward 
22 



338 



OPERATIONS FOR 



the stylet until it comes into the front of the mouth, at- 
tach a ligature in the eye of the instrument ; then fast- 
en a small piece of lint, spread with cerate or oil, or of 
moistened sponge not more than an inch (Fig. E,209,) 
long, to the ligature; and drawing the stylet back 
into the canula, withdraw the latter and fasten the 

Fig. 209. 




plug in the posterior nares by pulling firmly on 
the ligature, or on one portion of the double thread 
which was attached to it : thus leaving one portion 
of the thread in the mouth, the other in the nos- 
tril. On stuffing the front of the nostril with any soft 
substance, the whole passage will be firmly closed, and 
it only remains to fasten the thread coming from the 
mouth to the cheek, by adhesive plaster: or to tie the end 
from the nose and that from the mouth loosely together 
to complete the operation. If the hemorrhage has been 
excessive, the plugs may remain three days, or at all 
events until a clot forms on the bleeding surface. When 
it is wished to remove them, pick out that in the front of 
the nostril, and introducing a probe, push the posterior 



ARRESTING HEMORRHAGE. 339 

one into the throat: whence it may be drawn out of the 
mouth, by the thread that was left attached to it. 

If Bellocque's canula is not at hand, we may use a 
catheter with a double ligature fastened in its eye. 
This being passed through the nostril until the thread 
shows itself in the throat, it will be easy to draw the 
ligature out of the mouth by a pair of forceps : when 
after attaching the lint to it, the whole may be again 
drawn through the posterior nares and the thread con- 
fined as before. Sponge being softer and more ab- 
sorbent than lint, would be preferable as a plug, were 
it not, that it is apt to become very firmly wedged in 
the posterior nares in consequence of its expansion. 

HEMORRHAGE FROM THE RECTUM, 

Occasionally gives rise to most serious results, and re- 
quires to be arrested immediately, in order to preserve 
life. As in most cases it is the result of some operation 
upon the part, the most certain means of arresting it 
is to employ a rectum speculum, and if the vessel can 
be seen, to tie it. But when this is not possible, re- 
sort may be had to compression by means of cotton 
or lint stuffed into a bladder like a sausage, and forced 
into the gut. Cold water, or powdered ice may also 
be thus employed, provided caution is used, as to the 
effects of the cold on the system generally. The use 
of anything,however, thus introduced into the rectum, 
is accompanied by great inconvenience and difficulty 
of retention, from the expulsive efforts that it induces. 
In such cases, resort may be had to the actual cautery, 
after the plan of Dupuytren ; or where the bowel is 
kept distended with blood, the introduction of the 
nozle of a syringe, or a catherer, into the gut will 
probably prove useful by keeping it empty, and thus 
permitting the closer contraction of the parts about the 
bleeding vessel. 



340 OPERATIONS, ETC. 

HEMORRHAGE FROM THE BLADDER, 

Is not of frequent occurrence, and still less frequently 
of such an extent as to require direct interference. 
Should it however occur, the principle to be observed 
would be, to keep the bladder perfectly empty by the 
use of the catheter, and employ cold externally or 
even introduced to the inside of the bladder itself, by 
means of a syringe and catheter. 



WOUNDS. 341 

CHAPTER V. 

OF WOUNDS. 

These if of a simple kind and not involving parts of 
vital importance, generally require but little constitu- 
tional treatment : the attention of the practitioner being 
mainly confined to arresting the hemorrhage, remov- 
ing foreign matter, and promoting the union of the 
divided surfaces. Of the first, we have already 
spoken under its appropriate heading; the second 
will be treated of hereafter, and we shall therefore 
now confine ourselves to the third indication, or the 
union of the divided edges. 

Coaptation of wounds maybe accomplished by thriee 
means, that is either by Adhesive Straps; by Band- 
ages, as before stated, or by 

SUTURES. 

These stitches, are intended to approximate the 
sides of wounds, especially when seated in parts that 
are naturally loose and moveable. They are of five 
different kinds, as at present recognised, to wit : the 
Interrupted, Continued, Twisted, Quilled, and Dry. 

THE INTERRUPTED SUTURE, 

Which is the one most frequently employed, is made by 
introducing a needle similar to either of those in Fig. 
210, armed with a simple ligature, through one lip of the 
wound from without inwards, and through the other lip 
from within outwards, at such a distance from their 
edges as will prevent the stitches cutting out too soon. 
Then drawing or pressing the sides of the wound 
together, tie the ends of the ligature moderately tight 



342 



WOUNDS. 



in a double sailor's knot, (Fig. 208) taking care not 
to put too much strain upon the parts, lest they cut 
through the skin. In using the needle, carry it deep 

Fig. 210. 




enough to obtain a firm hoJd, but not so as to in- 
clude the tendons or fascia : making the requisite num- 
ber of stitches at about an inch apart, and supporting 
them if necessary with a few adhesive strips or a band- 

F/§-.211. 




age (Fig. 211, A). When afterthe lapse of two or three 
days we wish to remove them, seize the knot with a pair 
of fine forceps, and cuttingthe thread, withdraw itcare- 
fully from the part: leavingthe adhesive plaster for a day 
or two longer, if required to preserve the union. When 
sutures are allowed to remain a longer time than this, 
ulceration is induced, which eventually removes them. 
This leaves a ragged sore, and a more marked cica- 



WOUNDS. 343 

/ 
trix, and as all the advantages of their use are ob- 
tained in forty-eight or seventy -tw^o hours, we invariably 
cut them out: generally at the end of the second day. 
Sutures are not as much employed as they might 
be, on account of the horror that patient's enter- 
tain of the use of a needle, in the flesh, and also of pre- 
judice on the part of some surgeons. But the more 
perfect adhesion gained where the parts are moveable, 
and the greater certainty of the continued approxi- 
mation of the edges by these means, are strong in- 
ducements to their employment ; and we must confess 
our predilection for them to a greater degree than 
that of most other practitioners. 

THE CONTINUED SUTURE, 

Also called the Glover's Suture, is made by passing 
a needle and thread through and through the integu- 
ments as in ordinary sewing, (Fig. 211, B). It is 
however seldom employed, except in wounds of the 
intestines, and in sewing up dead bodies, after post- 
mortem examinations. 

Another mode of making the continued suture, and 
one that answers very well where it is desirable to 




make considerable traction on the threads, is that re- 
presented in Figure 212. The needle is passed as 
represented in the cut, and as it includes more or less 



344 WOUNDS. 

of the parts on the side of the wound, draws them 
together with almost as much firmness as the quilled 
suture. Like this, however, it is now but little used, 
but might we think be more frequently employed, in 
wounds of the thigh, buttock, &c. 

THE TWISTED, OR HARE-LIP SUTURE, 
Is made by introducing several pins through the sides 
of a wound at a depth sufficient to hold firmly, and 
then twisting a ligature around each extremity in the 
shape of a figure 8, (Fig. 211, C). In angular wounds, 
the first pin should be placed at the lowest angle, in 
order to ensure a regular adaptation of parts, 
and then the others introduced at equal distances, 
say half an inch apart. After forty-eight hours, the 
pins should be withdrawn by the forceps, with a slight 
rotatory motion ; but the ligatures may be left until 
loosened by the discharge, or subsequent dressings. 

In the selection of pins, there is much useless par- 
ticularity ; some surgeons directing silver pins with 
moveable steel points, in order that by their removal 
they may prevent the points injuring the adjacent 
parts ; others advising round, and some square points. 
But one great objection to these moveable points is, 
that if it is necessary to withdraw the pin a little, in 
order to vary its point of exit, the steel point is liable 
to be left in the flesh. Silver also has no advantage 
we think over other substances ; and the common cam- 
bric needles with sealing-wax heads, or a good stout 
pin of the ordinary kind will answer equally as well: 
as the point may be surrounded with a little pellet of 
wax after it is introduced, or it may be cut off by a 
pair of bone-nippers. 

A very good hare-lip pin may be made of steel wire, 
cut to any length and brought to a triangular point at 
one end, by a few touches of the file. We seldom 
employ any others. 

In placing pins after the operation for hare-lip, ron- 



WOUNDS. 



345 



isiderable advantage may be gained by passing a fine 
.ligature through each free angle of the part, previous 
to arranging the pins. By means of this ligature, it 
is easy to bring the edges to the same level, and 
guard against the central depression or indentation 
which so often results ; after the pins are placed, 
this ligature is to be removed. We have often noticed 
the difference in the result of the operations of the 
French and American surgeons in this respect, and 
believe the success of the former to be owing to this 
plan of operating. 

THE QUILLED SUTURE, 

Is intended for the union of deep seated parts ; but as 
its place can be well supplied by a compress and 
strips, or by a uniting bandage, it is not at present 
much employed. It is made by passing a number of 

Fiff. 213. 




double ligatures through the sides of the wound, 
and placing a little roll, or quill, or catheter, in the loop 
on one side and tieing the opposite endsaround another 
(Fig. 213). The ligatures acting on the quills, are en- 
abled to force the parts more closely together, without 
the risk of their cutting through the integuments. 



THE DRY SUTURE, 
Is made by fastening strips of adhesive plaster on 



346 WOUNDS, 



each side of a wound, and then approximating 
them, by tying together the ligatures introduced into 



Fig. 214. 




the strips of each side. (Fig. 214.) The difference 
between this and the interrupted suture is, in the 
former being passed through the adhesive strips, 
instead of through the integuments, as in the latter. 



CATHETERISM. 347 

CHAPTER VI. 
CATHETERISM. 

The introduction of tubes into the different pas- 
sages of the body, requires in the first place, an 
accurate knowledge of the anatomical relations of the 
parts, and then some skill in the manipulation of the 
instruments. In most cases, slow and gentle move- 
ments are to be made, rather than rapid and violent 
ones, and in the use of instruments, especially as 
applied to the urethra, the object should be rather to 
introduce it without attracting the patient's attention, 
than to take him, as it were, by storm : as we have 
occasionally seen done, by the would-be dexterous 
operators. 

CATHETERISM OF THE URETHRA. 

The passage in which catheters are most frequently 
employed, is undoubtedly the urethra. For this pur- 
pose the tubes are made of various shapes, sizes, and 
substance ; but to one acquainted with the anatomy of 
the part, their shape is a matter of little importance 

Fig-, 215. 




— a straight instrument passing quite as readily as a 
curved one. Generally, however, the male catheter is 
bent to the curve represented in Fig. 215 ; made 



348 



CATHETERISM. 



either of silver or caoutchouc cloth, and with an eye 
on each side, or with several perforations, according 
to the taste of the operator. When the gum-elastic 
one is employed, a wire or stylet is generally required 
to be introduced into it, in order to give the requisite 
stiffness, and prevent its yielding to any temporary 

Fig-. 216, 




obstruction that may be met with. In the introduc- 
tion of the instrument, the simplest proceeding will 
be found to be the following : 

Place the patient on his back, with the limbs 
and shoulders slightly elevated, in order to relax 
the abdominal muscles. Then, having oiled the 
instrument, take it in the right hand, by its mouth, 
and seizing the head of the penis between the finger 



CATHETERISM. 349 

and thumb of the left, so as to hold it perpendicularly 
to the patient's abdomen, place the catheter in the 
orifice of the urethra, and, whilst his attention is en- 
gaged by conversation or otherwise, slide the point 
of the instrument gently down the urethra until it has 
reached the arch of the pubis, or can be felt deep in 
the perineum. Then, gently depress the penis and 
catheter until the instrument is parallel with the pa- 
tient's thighs, when the point will suddenly slip over 
the triangular ligament and enter the bladder, as 
is at once known by the escape of urine. The cut 
(Fig. 216), represents the position of the instrument 
at the moment when it is to be laid parallel with the 
thighs. Should the patient strain, or resist the ope- 
ration, let him rest for a moment, and pass the left 
hand gently over the abdomen, so as to promote re- 
laxation of its muscles ; then try again to keep him in 
conversation, so as to prevent his holding his breath. 
But should there be no stricture of the urethra, little 
difficulty to the introduction of the catheter need be 
anticipated. 

Various other plans have been recommended, 
either for the surgeon's convenience, or to enable 
him to astonish the by-standers ; but the above plan 
embraces the simplest means, and is the practice 
of M. Civiale, who is probably the most beautiful 
operator in such cases, at present existing. 

In old men, the introduction of the catheter is occa- 
sionally a matter of considerable difficulty, owing to 
the enlargement of the third lobe of the prostate 
gland, which, from its projection into the canal, re- 
quires a modification of the instrument. In order to 
overcome this difficulty, it is necessary to elevate the 
point of the instrument more than in ordinary cases, 
as in Fig. 217. This may be accomplished either by 
bending the point slightly, previous to its introduc- 
tion, by passing it for an eighth of an inch into the 
barrel or ward of a pocket-key : or by introducing a 



350 



CATHETERISM. 



finger into the rectum, when the catheter has reached 
the gland, and thus elevating the point. Or if the flexi- 
ble catheter is used, withdraw the wire for a short 

i'V-217. 




distance, and then pass the instrument forwards to- 
wards the bladder. 

In cases of paralysis, or of a tight stricture, it is 
frequently necessary, in order to save trouble, to re- 
tain the catheter in the bladder for several hours. In 
such patients, after having evacuated the urine, place 
a little plug or cork in the extremity of the instrument, 

Fig, 218. 




in order to prevent the constant flow of water, and 
fasten the catheter either by attaching it with tape to 
a suspensory bandage, as represented in Fig. 218, 



CATHETERISM. 351 

or, tie the tapes firmly around the end of the in- 
strument ; surround the body of the penis with a few 
turns of narrow bandage : and then either sew the 
tapes to it, or confine them by circular turns of another 
piece of tape, as represented in Fig. 219, taking care 




not to draw them too tight. As the organ is, how- 
ever, liable to changes of size, the plan first treated 
of (Fig. 218), is, we think, preferable to this, or most 
of the others that have been proposed. 

CATHETERISM OF THE STOMACH, 

Or the introduction of a tube for the use of the sto- 
mach-pump, is performed generally without any diffi- 
culty, except that arising from the resistance of the 
patient in certain cases. Guarding, then, against the 
closing of the patient's teeth upon the fingers of the 
operator, or upon the tube, by placing a plug of wood 
or a knife handle between the jaws, pass the point of 
the tube directly back into the throat with the right 
hand, and with the fore-finger of the left, depress 



352 CATHETERISM. 

its point, when it is not bent in consequence of the 
resistance of the posterior walls of the pharynx, as 
represented in Fig. 220. The course of the oesopha- 

Fiff. 220. 




gus renders the subsequent progress of the instrument 
perfectly easy. 

When it is necessary to w^ash out the stomach, or 
to introduce food, any of the various stomach-pumps 
that please the fancy of the operator may be used ; 
but a common injection syringe will be found to equal 
all the purposes of the more complicated instruments. 

In the use of the liquids to be introduced into 
the stomach, particular attention should be paid to 
their temperature : as the patient, from being de- 
prived of the use of his mouth during their introduc- 
tion, might otherwise be seriously scalded, either in 
the oesophagus, or stomach. Some practitioners re- 



CATHETERISM. 353 

commend smearing the tube with molasses, oil, or 
mucilage, previous to its introduction. To this there 
is no objection, except that it is not absolutely ne- 
cessary, as dipping the tube into simple cold water 
answers equally as well, and is generally more con- 
venient. On withdrawing the tube from the stomach, 
the operator should be careful, always to place a finger 
on its open end, so as to close it tightly, and thus 
prevent the escape of any liquid that might remain in 
the tube, into the trachea, as the tube passes the pha- 
rynx. 

CATHETERISM OF THE EUSTACHIAN TUBE, 
Is occasionally required, in order to overcome ob- 
structions in the passage, which produce deafness by 
preventing the passage of sound along the canal. 
Without, however, pretending to define the cases re- 
quiring this operation, we shall here simply refer to 
the operation itself, from a belief that many who are 
fully aware of its utility would perform it, were it not 
from some indefinite idea, drawn usually from the 
prolix directions of the French aurists, that they pos- 
sess of its difficulty. 

A slight reference to the anatomical structure of the 
part will show that there can be no very great mystery 
in the operation. The opening of the Eustachian tube 
into the pharynx, being about a quarter of an inch be- 
hind the soft palate, is placed on a line with the poste- 
rior end of the inferior turbinated bone. Its orifice is 
rounded or oval ; is capable of receiving the tip 
of the little finger, and reposes against the side of the 
internal pterygoid process of the sphenoid bone. Its 
size, consequently, enables it to receive the point of 
the catheter for this tube, with little or no difficulty. 

In introducing it, place the patient's head firmly 

against the back of a chair, and having oiled the end 

of the instrument, pass it through the nostril of the 

side affected, with its point resting on the floor of the 

23 



354 CATHETERISM. 

nose, and with its convexity upwards, until it reaches 
the posterior nares and the rounded edge of the soft 
palate, which may be readily told by the patient's 
gaging. Then turn the point of the instrument out- 
wards, towards the side affected, and it will generally 
slip into the tube (Fig. 209, B). As the operation, 
when employed in deafness, requires to be frequently 
repeated, it is well to mark upon the catheter the dis- 
tance from the front of the nose to its point, when in- 
troduced into the orifice ; in order to facilitate its sub- 
sequent application . The inj ection of air, or of liquids, 
will, of course, depend upon circumstances. 



INJECTIONS. 355 



CHAPTER VII. 

INJECTIONS, 

Or the introduction of liquids into the various 
passages of the body, are generally performed with a 
view to the relief of local derangement or to excite 
local action. They are used in the lachrymal ducts, 
the urethra, the vagina, rectum, &c. 

INJECTION OF THE LACHRYMAL DUCTS, 

With the view of removing inflammation, or some 
obstruction to the passage of the tears, is performed 
by means of a fine capillary pointed syringe, known 
as Anel's. In using it, take the syringe in the right 
hand, between the thumb and middle-finger, with the 
fore-finger on the piston, so as to enable the operator 
to throw in the fluid : and standing either in, front or 
behind the patient, according to the eye to be ope- 
rated on, place the point of the syringe in the lower 
punctum, and introduce it only sufiiciently far to pre- 
vent the escape of the liquid. Then, closing the 
punctum of the upper lid, throw in the fluid by 
moving the piston with the fore-finger of the right 
hand. If it passes through the duct to the nostril, its 
passage will be shown by its escape either from the 
nose in front, or into the mouth of the patient behind. 
Simple water, or that containing a little astringent 
solution, is generally used where the object is to clear 
the passage and overcome the inflammation of the 
ductus ad nasum, &c., and, when the syringe is pro- 
perly employed, is a useful means of preventing the 
production of fistula lachrymalis. 

Another plan, lately proposed, of cleansing this 



356 INJECTIONS. 

duct, is by the introduction of a catheter into the 
opening of the duct in the nostril, as in A, Fig. 209. 
Though comparatively simple, it is much more diffi- 
cult than the plan just stated, and being opposed to 
the natural course of the tears and the anatomical 
structure of the part, is not generally resorted to. 

As the capillary perforation of the point would ren- 
der it difficult for us to fill the syringe with it on, 
they should always be made moveable, and only ap- 
plied as a nozle to the syringe, after the latter is 
filled. Sometimes, when the puncta lachrymalia as 
well as the ducts are closed, it becomes necessary to 
dilate them previous to the use of the syringe. This 
may be done by a fine hair-like probe also known as 
Anels's, or by the blunt end of a fine cambric needle, 
nicely rounded oflf and fastened in a light handle by 
its point. 

INJECTION OF THE LUNGS, 

Is confined, of course, to the use of air, where the 
patient, from any circumstances, is incapable of car- 
rying on his own respiration. In cases of asphyxia 
or drowning, especially the former, whether in adults 
or infants, it is often an operation of vital importance, 
and one which has consequently given rise to various 
plans and instruments for its performance. Being 
generally an act of great emergency, it is fortunate 
that the operator always has the best and simplest 
means about him ; in the use of his own lungs. In 
order, then, to fill the chest and keep up artificial 
respiration, place the thumb and fore-finger of one 
hand closely around the patient's lips, and let the 
operator adjust his own mouth to this, whilst, with 
the other hand, he presses the pomum adami back 
against the vertebrae, so as to close the oesophagus, 
and prevent the air passing to the stomach. Then 
direct an assistant to compress the patient's nostril 
and to press upon his ribs whenever the lungs have 



INJECTIONS. 357 

been inflated by the breath of the operator ; the latter 
of whom should free the patient's mouth after each infla- 
tion, — thus inflating and expelling the air, so as to imi- 
tate as much as possible the natural process of respi- 
ration. In cases of drowning, no time should be lost 
before commencing this operation, as it is generally 
the only chance that the individual has for life. 

INJECTIONS INTO THE URETHRA, 

Of the male, are generally performed by the patients 
themselves. But as many are ignorant of the proper 
mode of perfoming them, and bring on inflammation 
by bruising the sides of the urethra upon the syringe, 
it is better for the surgeon to give them special direc- 
tions in regard to the manner of employing it, or per- 
form the operation himself once or twice, until the 

Fig, 221. 




patient has learned how. In order to use these injec- 
tions properly, the patient should be directed to fill 
the syringe and insert its end gently within the ure- 
thra, closing the orifice around its point, as in Fig. 
221. Then sitting down on the edge of a chair or 



358 INJECTIONS. 

bed, or upon a ball made by rolling up a handkerchief 
or stocking, so as to press upon the perineum, throw 
the fluid in by a motion of the piston, as in the figure, 
and, withdrawing the nozle, close the urethra quickly 
and hold the injection for a few minutes ; then repeat 
the operation twice or three times as before. An 
attempt to urinate will evacuate it without difficulty. 

INJECTIONS INTO THE VAGINA, 
Like those into the urethra of the male, are not often 
required to be performed by the practitioner, yet, 
owing to the ignorance of the patient, much of the 
benefit likely to result from their proper performance is 
lost. In the use of the ordinary female syringe, the 
patient should always be directed to lie down on her 
back, with the hips raised, and to retain the liquid 
used, as long as possible, by pressing a cloth against 
the vulva. But wherever it can be done, the substi- 
tution of the French clyso-pompe or self-injecting 
apparatus, should always be insisted on : as by using 
this instrument, a much larger amount of fluid can be 
thrown into the passage, and its whole surface more 
thoroughly acted on by it. The vaginal nozle of the 
self-injecting apparatus being placed on the tube and 
the patient seated over a basin, she can herself use a 
pint or more of any fluid for a considerable length of 
time, or, if necessary, by being down and arranging 
the instrument, have the syringe used by an assistant 
without exposure. In cases of leucorrhoea, &c., ac- 
companied as it often is by extreme debility, this plan 
will be found highly serviceable. 

INJECTIONS INTO THE RECTUM, 

Although generally performed by the attendants, yet 
occasionally fall to the lot of the practitioner, espe- 
cially after operations in the neighbourhood of the 
part; and the comfort of the patient will be found to be 
much involved in their proper application. In France, 



INJECTIONS. 359 

these useful means of treatment are very frequently- 
resorted to, whereas it is but seldom a patient can be 
persuaded to employ them in this country, owing, in 
a measure, perhaps, to prejudices, but also, as we 
have been often told, to the pain they cause. Now, 
if properly given, their use is productive of little or 
no pain, even in cases of hemorrhoids. 

In order to give one without causing pain, oil the 
fore-finger of the left hand, and press its point gently 
against the sphincter ani muscle, till its contraction is 
overcome and the finger enters the gut. Then pass 
the nozle of the syringe, also well oiled, along the fin- 
ger, as a director, till it also enters the gut, when, with- 
drawing the finger, the fluid can be thrown in without 
difficulty ; care being taken to keep the point of the 
syringe in the line of the concavity of the sacrum. 
The position of the patient and the liquid employed, 
must depend upon circumstances: but generally the 
patient is most comfortable lieing on the left side, with 
his back to the attendant. 



360 EXTRACTION OF 

CHAPTER VIII. 
EXTRACTION OF FOREIGN BODIES, &c. 

Under this head, we propose to arrange a class of 
minor operations, which require very little division 
of tissue, yet involve the performance of duties which 
to be successful must be learned rather from practice 
and common sense, than from detailed directions. We 
shall here, therefore, as in other parts, be very brief in 
our remarks. In some of these operations, we know 
also, that we trench upon the specific duties of those, 
without the bounds of the profession ; but as the sur- 
geon may often supply their places, with great ad- 
vantage to the public, we have deemed it best not to 
pass them by. 

EXTRACTION OF TEETH. 

The operations upon the teeth being very generally 
performed by a particular class of persons, the sur- 
geon is seldom consulted in regard to them, except 
w-hen connected with other affections. Were it not 
then for these cases, and for the fact that in country 
practice, the medical man is often the only one who 
can render assistance, we should omit them entirely : 
as beneath the position which the practitioner holds in 
the estimation of the public. We shall, therefore, con- 
fine ourselves to such portions only of this subject, as 
are likely to be required of the surgeon, viz.. Extraction. 

The Extraction of teeth may be performed either 
with the Forceps or with the Key : the former being 
generally, the preferable instrument. The instru- 
ments, however, as employed by dentists, are va- 
ried in number and shape : but for ordinary use the 
straight, curved, and hawk-bill forceps, are all that 
are necessary. As certain teeth require some little 



FOREIGN BODIES. 



361 



modifications of the general plan of operating, we 
shall treat of each respectively. 

In extracting the Incisors and Canine Teeth of the 
Upper Jaw, the operator should grasp the straight 



Fi^. 222. 




forceps, firmly, and seize the tooth just at its junction 
with the gums, taking care not to compress it with 
such force as to crush the crown of the tooth in the 
instrument. Then giving it a slight twist, so as to 
loosen the tooth in the alveolar process, pull it per- 
pendicularly downwards and slightly backwards, in 
the direction of the alveolar cavity. 

In extracting the Bicuspid and Molar Teeth of the 
Upper Jaw, use the hawk-bill forceps, or those es- 
pecially made for the molar teeth, and moving the 
tooth from side to side, pull perpendicularly down- 
wards. (Fig. 223.) 

The extraction of these teeth in the Lower Jaw, is 
similar to those in the upper, except, as to the dif- 
ferent direction required in extracting them, which 
common sense will render sufficiently apparent. 



362 EXTRACTION OF 

Many operatorslance the gums, previous to the appli- 
cation of the instrument to the tooth, especially in the 

Fiff. 223 




molars and bicuspides ; others, again, deny the neces- 
sity of it, except when the key is employed. It may, 
we think, safely be left to the judgment of the 
operator. 

In extracting the Molars and Bicuspides, with the 
Key of Garangeot, or its modifications, wrap the ful- 
crum with some soft substance, in order to protect 
the soft parts from pressure. Then place the fulcrum 
on the inside of the jaw, so that the claw may em- 
„. 224 brace the tooth, just at its junction 

* with the alveolar process, (Fig. 224) 

and rotating quickly the handle of the 
instrument, draw the tooth from the 
socket. Should it not be freed en- 
tirely, by these means, it must be 
seized by the forceps, and extracted 
as before mentioned. 

For those, who by practice have ac- 
quired the command of this instru- 
ment, we believe that it will be found 
to answer exceedingly well for the 
extraction of these teeth, or of stumps. Care, however, 
is required, lest the claw be placed upon the edge of 
the alveolar process, and the bone be thus fractured, as 
is occasionally done. If, through inattention, or owing 
to the seat of decay in the tooth, the fulcrum is not 
placed on the inside of the jaw, crushing of the alve- 
olar process is very apt to follow ; and special attention 




FOREIGN BODIES. 363 

should be given to the action of the fulcrum, in such 
cases, in order to avoid it. 

The extraction of Stumps, when not accomplished 
hy the Key, requires the use of the Elevator ; the point 
of which should be firmly thrust down between the 
stump and the socket, and then using the finger : a 
sound tooth, or the edge of the alveolar process, as a 
fulcrum, pry out the roots. But as the point of the 
elevator is exceedingly liable to slip and wound the 
cheek, the point of another finger, wrapped with cloth, 
should always be placed between the stump and cheek. 

The excessive hemorrhage, which sometimes fol- 
lows the extraction of teeth, not unfrequently causes 
considerable trouble, although generally it may be 
arrested like that following leeching, by the use of 
nitrate of silver, or by a compress, forced into the 
cavity, unless it should arise from constitutional 
causes. A prescription recommended by Dr. God- 
dard, in his work on the teeth, is the following : — 
*' Cause some alcohol to dissolve as much of the fol- 
lowing substances, as it is capable of doing, so that 
it may be a saturated tincture ; namely, Secale Cor- 
nutum, and Gallic acid ; then add about one-fourth 
of Creosote, by measure. This tincture may be ap- 
plied, by holding it to the part, or may be used to satu- 
rate the lint used in plugging the cavity, should that 
measure become necessary. Ergot, in the form of a 
watery solution, may, also, be used with success in 
many cases, as a gargle or mouth wash ; especially 
when the hemorrhage comes from the gums." 

Those practitioners who may be compelled to ope- 
rate upon the teeth, will find much valuable, scien- 
tific, and practical information, in the work referred to. 

EXTRACTION OF CILl^. 
In Trichiasis, or turning in of the eye-lashes, or in 
a supernumerary growth of the individual cilise, the 
constant rubbing of the hairs against the delicate sur- 



364 EXTRACTION OF 

face of the eye-ball, produces congestion of its vessels, 
and more or less serious inflammation ; often indeed 
to such an extent, as to impair the transparency of the 
cornea. Under these circumstances, the lids should 
be slightly everted, and their edges examined, so as 
to detect the seat of irritation : when the cilise may 
be pulled out by a pair of forceps, accurately adjusted 
at the points of the blades. But in obstinate cases, 
the most careful extraction of the lashes will not 
remedy the disease ; because, as long as the follicle 
remains in the lid, the hair may be reproduced. 
Having then carefully removed the lash, the bulb or 
follicle should be thoroughly cauterised by passing a 
piece of nitrate of silver along the edge of the lid, or 
into the opening left by the extraction of the eye-lash. 

EXTRACTION OF FOREIGN BODIES FROM THE 
EYE-BALL. 

Blacksmiths, and other workers in metals, not un- 
frequently suffer from sharp particles of foreign matter 
being driven into the eye-ball, so as to become firmly 
imbeded in its outer coats ; thus producing a most 
painful affection. These little particles are also often 
so fine and brittle, as to render it impossible to ex- 
tract them by forceps, and all such attempts not only 
fail, but render the matter infinitely worse, by breaking 
the piece. It will, therefore, frequently be found to be a 
better plan, to take a fine cataract needle, wuth a slight 
curve, and opening the lids widely, place the convex 
surface of the needle flat against the ball of the eye, 
and glide it gently over its surface. On reaching the 
piece it will generally draw it out, and cause it to fall 
upon the lid, or into the hand of the operator. But if 
this fail, the touch will indicate precisely the point of 
the particle, if it projects at all beyond the surface, 
and its extraction may then be eventually effected by 
repassing the edge of the needle against the foreign 
substance, and moving it downwards or upwards, ac- 
cording to the angle at which it projects, so as to 



FOREIGN BODIES. 365 

shave or chip it out ; an expression which we presume 
will be understood. 

EXTRACTION OF FOREIGN MATTER FROM THE 
EYK-LIDS. 

In these days of locomotives and rapid travelling, 
the introduction of sparks and particles of sand be- 
tween the lids and the ball, is frequently productive 
of considerable trouble ; so much so, that the appoint- 
ment of an eye-cleanser to such public conveyances 
w^ould be a desideratum. When all simpler means 
have failed, and application is made to the surgeon, 
he should seize the edge of the lid with the fingers of 
one hand, and pressing the point of a pencil, or other 
round instrument, against its outside, evert the lid, so 
as to turn it completely inside out. Then, when its 
inner surface is thus exposed, a camel's hair pencil, 
a fine rag, or a piece of moistened soft sponge, will 
easily wipe away the offending matter. 

EXTRACTION OF FOREIGN BODIES FROM THE 
NOSTRIL. 

Coffee grains, pebbles, ribbon, &c., are occasionally 
introduced and become fastened in the nostrils of chil- 
dren ; thus giving rise to violent inflammation and 
suffering, and causing considerable difficulty in their 
removal. With a proper knowledge, however, of the 
structure of the part, a scoop, or the curette of Leroy 
d'Etiolles, or polypus forceps, will generally suffice 
to accomplish the desired end. But if these fail, 
resort may be had to sternutatories, or to washing out 
the nostril with a syringe, and to the use of such 
means as will combat the inflammation. 

EXTRACTION OF FOREIGN BODIES FROM THE 
EAR, 

Is to be accomplished by somewhat similar means, 
although the operation here is by no means an easy 
one. When sufficient space exists between the sides 
of the external meatus and the foreign substance to 



366 EXTRACTION OF 

permit the use of a syringe, a full stream of tepid 
water, thrown in whilst the ear is drawn upwards and 
backwards, will generally be found to answer for its 
removal. But in the use of the forceps, care must 
be taken not to force the substance further in. In 
the case of insects, as earwigs, &c., which occasionally 
get in as far as the membrana tympani, and cause 
excruciating pain, the free use of warm olive or al- 
mond oil, by closing their pores, will generally pro- 
duce their death, or cause them to seek the open air 
at the orifice : when subsequent syringing with tepid 
water will generally remove them. The use of lauda- 
num, and other stimulating articles, should be avoid- 
ed, as they increase, instead of relieving the distress. 

EXTRACTION OF FOREIGN BODIES FROM THE 
THROAT, 

Is an operation which frequently affords the practi- 
tioner but little time to make his arrangements, and 
in which, therefore, it is desirable that the instruments 
required should be made of materials readily obtained. 
We find, therefore, probangs, or pieces of whale- 
bone with a lump of sponge tied fast to one end, 
the handle of a riding-whip, the fingers of the ope- 
rator, &c. , among those most frequently recommended. 
As the nature of the object swallowed may not, how- 
ever, be such as to cause instant suffocation, but, on 
the contrary, allow suflScient time to elapse for the 
development of inflammation, we shall confine our 
remarks to the latter ; simply glancing at the causes 
of the spasm and irritation usually produced by bodies 
lodged in the pharynx. 

In the North American Medical and Surgical Jour- 
nal, for October, 1828, will be found an extensive 
article on this subject, by Dr. Henry Bond, of Phila- 
delphia, from which we shall mainly condense our 
statement. Dr. Bond states that foreign bodies are 
most frequently arrested so high in the fauces or pha- 
rynx, that they may be seen, simply by depressing the 



FOREIGN BODIES. 367 

tongue, and that in such cases, the finger or dressing 
forceps will suffice for its removal ; whilst it is at this 
point they induce spasmodic action of the muscles 
of the glottis, by which the matter becomes im- 
pacted between the bones of the oshyoides and the top 
of the thyroid cartilage. This spasmodic closure of 
the glottis, produced by the irritation of the foreign 
body, induces spasmodic efforts of coughing, in order 
to throw it off. But the pressure upon the epiglottis 
preventing the inspiration necessary for coughing, 
suffocation ensues, unless the article is quickly 
removed. Now, in such cases. Dr. Bond recommends 
that the patient's head be held erect, and in such a 
manner as to make the chin project as little as possible 
beyond the pomum adami, so as to render the intro- 
duction of the finger more easy, and thus release the 
article from its position, so that it may readily be 
ejected. But where the objects are smaller, where 
they descend further and pass the larynx, though the 
risk of suffocation is diminished, the difficulties of ex- 
traction are increased. For such cases, resort must 
be had to forceps, of which nothing can be better than 
the oesophagus forceps of Dr. Bond, which are now 
generally kept by the cutlers, and which every prac- 
titioner should possess. These forceps are twelve 
and a-half inches long, and curved to suit the shape 
of the throat, so that they will reach as far as the 
top of the sternum — a point, beyond which little 
difficulty is usually felt from foreign bodies. 

The blades being also bevelled off so as to avoid 
pinching the coats of the oesophagus, and serrated, 
are capable of seizing even small bodies, as a pin 
or fish-bone, without risk of injury to the passage. 
When coins, pieces of glass, or similar articles, are 
in question, the use of the forceps is decidedly the 
best way of removing them ; but when these are not 
at hand, a piece of common wire, bent round and 
formed into a loop, with the free ends firmly twisted 



368 EXTRACTION OF 

together, and the loop then bent into a hook, may- 
supply their place, or in some instances supplant 
them. Dr. Bond makes several other excellent sug- 
gestions, which, for want of space, we must refer those 
desirous of learning, to the original article, as quoted. 

THE EXTRACTION OF FOREIGN BODIES FROM 
THE TRACHEA, 

When not affected by coughing, cannot be readily 
accomplished by mechanical means, without making 
an incision into the anterior parietes of the tube ; but 
sudden blows w^ith the hand upon the cervical verte- 
brae, the use of sternutatories, or the efforts to cough 
induced by irritating the larynx with a feather, will 
occasionally suffice. Should the substance, however, 
so obstruct the passage as to threaten death, an in- 
cision one inch and a-half long, directly on the me- 
dian line of the trachea should be made, so as to di- 
vide the integuments ; the blood be thoroughly sponged 
off, and then two or three of the rings divided. The 
entrance of air through the opening will generally 
drive out the foreign substance. But, if it does not, 
a probe or director should be introduced through the 
wound, and the body pushed upwards. 

Tracheotomy is, however, an operation of consider- 
able danger, and we only call attention to it as thus 
performed, in cases where, without it, certain death 
would ensue ; it being, we think, a good rule to give 
every man a chance for his life, or to let him die of his 
doctor as soon as from his disease — provided the 
latter point is certain. 

THE EXTRACTION OF FOREIGN MATTER FROM 
WOUNDS, 

Requires the use of forceps which are modified ac- 
cording to circumstances, and generally treated of in 
the works on Gun-shot Injuries. But when the sub- 
stance is only particles of dirt, or such fine matter as 



FOREIGN BODIES. 369 

cannot well be seized by the forceps, the free use of 
a stream of tepid water either by means of a syringe or 
from a sponge, will suffice. 

THE EXTRACTION OF FOREIGN BODIES FROM 
THE RECTUM, 

May be accomplished by the use of a scoop or spoon 
handle : especially when employed with a speculum, 
and when the body is seated near the verge of the anus. 
But in the case of such substances as by their sharp 
projecting points would be likely to become im- 
peded in the side of the gut, the means employed 
by iMarchetti in extracting the tail of a pig with stiff 
bristles from the rectum of a courtesan (as reported in 
Gibson's surgery,) may be resorted to. This consisted 
in the introduction into the rectum of a hollow reed, 
the end of the tail being passed throuq^h the reed so 
as to incase it : thus protecting the gut from the action 
of the sharp projecting points. 

The recollection of this simple plan will, we think, 
enable any one to apply its principle to numerous other 
instances, both in the rectum and elsewhere. When 
glass pessaries, &c., become broken in the vagina, 
some such contrivance, which common ingenuity will- 
readily suggest, would prove highly useful for its re- 
moval, without injuring the sides of the canal. 

THE EXTRACTION OF FOREIGN BODIES FROM 
THE URETHRA, 

Embraces so much that is connected with the treatment 
of Calculus, that we must refer to the works upon Stone 
and Gravel, for the consideration of the means required. 

EXTRACTION OF CORNS. 

Cornsare a thickening ofthe Epidermis in consequence 

of pressure, and resemble a nail in shape : cause pain 

by pressure of the point on subjacent parts, and are 

generally treated by the public at large by filing, 

24 



370 EXTRACTION OF 

scraping or cutting off the upper layer : which by pre- 
venting the boot from pressing the central hardening, 
upon the sensitive cutis vera, relieves the pain. 

In the same way the various corn plasters &c., era- 
ployed for their relief prove serviceable ; that is either 
by softening the induration and favouring its exfolia- 
tion, or by removing pressure. 

Now without pretending to interfere with the busi- 
ness of certain Chiropodists, we would state two 
plans of treatment which the practitioner can em- 
ploy with marked benefit. First, the corn plasters of 
Sir Astley Cooper. These consist of pieces of buck- 
skin of the size of a ten cent piece, spread with adhe- 
sive plaster and having an opening in the centre 
of the size of the corn. This plaster being warmed, 
is so placed that the corn will project through the 
opening, and if one piece is not thick enough to rise 
above the top of the corn, one or two more must be 
placed on top of it, until the corn being relieved from 
pressure ceasesto act upon the true skin : thus removing 
the pain. The application of the pressure of the boot 
upon the circumference of the plaster, tends also ra- 
pidly to remove the corn, by forcing its central portion 
out through the opening. 

But should more permanent relief be desired, the 
corn may be entirely removed by the following 
plan : Soak the foot thoroughly in warm water for 
an hour. Then with a small round-bellied scalpel, 
cut through the first layers of the hardened skin just 
on the edge of the healthy tissue. Seize the edge thus 
loosened with a pair of dissecting forceps and con- 
tinue to dissect round the corn, on the edge of the 
healthy skin, but not cutting into it, till the pink cutis 
vera is reached at the bottom of the little cavity thus 
made. Then to ensure the entire destruction of the 
spot, touch the bottom with nitrate of silver, and thus 
prevent the re-appearance of the disease at this point. 
But if tight shoes, continue to press upon the skin, 
new corns will inevitably be created. In this little 



y" 



BUNNIONS AND CORNS. 371 

operation, no blood should be drawn, and relief will 
be afforded for a long period. 

EXTRACTION OF BUNNIONS. 

When the anterior portion of the metatarsal bone of 
the big toe is subject to long continued pressure, a 
bursal formation is induced, which by its increase, 
creates severe and painful inflammation or even ab- 
scesses in the surrounding soft parts (Fig. 225). These, 

Fig. 225. 




like corns, may be cured, simply by removal of pres- 
sure. The use of Cooper's plaster, cut to fit the 
increased size of the tumour, will therefore prove ser- 
viceable. But when they produce more serious effects 
than mere pain, the only plan will be to excise the 
cyst by careful dissection and cauterisation, guarding 
of course, against any injury to the subjacent joint. 

Connected with these parts, wehave now to consider 
a small sore that is often productive of such serious 
pain and inconvenience, as to have engaged the atten- 
tion of surgeons for a long period, and called forth 
many proposed plans of cure. We refer to 

THE TOE NAIL ULCER, 
Or that state of things which is induced by what is 
improperly termed the Inverted Toe Nail. This as 
seated in the Big Toe is usually the consequence of 



372 TOE NAIL ULCER. 

the pressure of the boot upon the inside of the toe, in 
consequence of which the skin on the opposite edge 
of the nail becomes bruised and inflamed. Or it may 
arise from the integuments being forced up over the 
nail, thus inducing inflammation, ulceration and the 
fungus represented in Fig. 226. 

Various means have been proposed for the relief of 
this truly painful aflection, in nearly all of which the 
nail has been treated as the *' fons et origo" of the dis- 
ease and we have excision, eversion, cauterisation and 

Fi^. 226. 




numerous other equally agreeable means, highly lauded: 
all of which if efl^ectual (and this seems doubtful) create 
a degree of pain which whilst it lasts is not surpassed by 
any other operation in surgery. Now all this we would 
humbly suggest, may be avoided by the following 
plan which we believe is due to Dr. Charles D. Meigs 
of the Jefferson College of Philadelphia, and which 
we have several times found efficacious. 

Scrape the nail or soften it in warm water so as to 
render it moderately flexible, and then introduce 
under its angle on the sore side, some soft lint or 
charpie, so as to fill entirely, the space beneath its 
edge. Next apply a very small compress upon' the 
granulations or tumefied or projecting integuments, 
in order to force them off' the edge of the nail, and 
confine it there by a few turns of a little strip of ad- 



• INSERTION OF EYES. 373 

hesive plaster. The continued pressure of the com- 
press, the action of the lint and the use of a loose 
shoe, will suffice for mild cases. But in more severe 
ones, the reduction of the surrounding inflammation, 
the removal of the granulations by nitrate of silver or 
excision, should precede the other means. 

We shall now treat of several other operations 
likely to invite the daily attention, of the young prac- 
titioner, but which, we cannot class under any par- 
ticular head, such as the following : 

INSERTION OF GLASS EYES. 

When from any cause, the ball of the eye has been 
injured and vision destroyed, it becomes desirable 
to conceal the deformity, the use of a Glass Eye must 
be resorted to. These consist in sections of spheres 
accurately coloured to suit the different appearances 
of the human eye, and intended to be placed in front 
of the remains of the injured ball: where the pres- 
sure of the eye-lids retain it in its position, and the 
action of the stump or remains of the eye, gives it 
motion. So perfectly is this sometimes the case, that 
unprofessional observers have not been able to tell 
the glass eye from the sound one. 

These eyes being now imported in considerable 
numbers and at moderate prices by Bauersach, Mar- 
ket Street, Philadelphia, Milhaud, Broadway, New 
York, and many others : and as their insertion is 
very simple, we hope the Profession will more fre- 
quently employ them to conceal deformities, which 
are often a constant source of mortification to the pa- 
tient. They will do away with the advantages now 
reaped by charlatans, at their expense. 

Introduction. — After having selected an eye of the 
color, size of pupil, and prominence of ball, that is 
desired : seize it between the thumb and fore-finger of 
the right hand, and dip it into a glass of tepid water. 
Then elevate the upper eye-lid, by the thumb of the 
left hand, and sliding the glass eye under its edge, 



374 GLASS EYES. • 

let the lid fall gently upon it. Next, depress the 
lower lid by the middle-finger of the left hand, 
and slip the false eye within it : when the subsequent 
action of the lids, will retain it in its place, and give 
the proper central position in the orbit. 

In order to remove it, take a bodkin, or short probe, 
and depressing the lower lid, slip its triangular end be- 
tween the lid and the ball and slightly under the edge 
of the glass eye. Then depressing the other extremity 
on the cheek, so as to make it act as a lever, catch the eye 
with the left hand, or in a handkerchief held to re- 
ceive it. After its removal, cleanse it in a little water ; 
dry it thoroughly and put it away in soft cotton in order 
to preserve an equaltemperature,tillit is again wanted. 

These movements are so simple that patients readily 
introduce and remove the eye themselves- At first 
the glass eye should only be worn three or four hours, 
lest it produce inflammation of the ball on which it 
is placed : but afterwards, it may be worn for any 
length of time. 

In the selection of eyes, care should be taken to see 
that they are perfectly smooth on the edges, as other- 
wise they will irritate the ball. But we do not think it 
necessary to use first a small eye and then another dur- 
ing several weeks, in order as is said, to dilate the 
lids, unless we wish as eye doctors do, to mistify the 
patient with the difficulty of the operation. 

EXCISION OF PTERYGIUM. 
When the vessels of the conjunctiva become per- 
manently enlarged, a thickening of this membrane and 
of the sub-conjunctival cellular substance results, 
which by extending over the cornea, interferes with 
vision. This diseased portion is usually of a trian- 
gular form, and commencingat the inner canthus of the 
eye, gradually diminishes in breadth, till it terminates 
by a sharp apex, somewhere on the edge of the cor- 
nea. Though generally single, we occasionally find 
more than one, (Fig. 227), and in such cases their 



PTERYGIUM, ETC. 



375 



continued growth soon destroys the patient's sight. 
When the prolongation of a pterygium seems likely 
to extend to the pupil, and to interfere with vision, 
it should be operated on. This may be done, either 

Fi^. 227. 




by seizing the enlarged conjunctiva with a pair of 
fine forceps, or with a hook. Then drawing it off 
from the sclerotic coat, cut out the central portion, 
with its vessels, by a snip of the scissors : cutting from 
the cornea towards the internal canthus of the eye, 
and taking care not to include the plica semilunaris. 
Or if the base of the pterygium is not very wide, 
make a simple transverse incision through it, down 
to the sclerotica, at a point half-way between the 
internal canthus and the edge of the cornea, so as 
to divide entirely, the vessels supplying the growth. 
Then pass a sharp-pointed stick of nitrate of silver in 
the line of the incision, and cauterise its edges; so 
that the circulation being destroyed in the part, the 
enlarged membrane may shrivel away. 

EXCISION OF THE UVULA, 
Is frequently rendered necessary, in consequence of 
the elongation of the extremity of its mucous mem- 
brane, which falling upon the posterior portion of the 
tongue and pharynx, or even in some instances, into 
the glottis, or upon the epiglottis, keeps up a con- 



376 EXCISION OF UVULA, ETC. 

stant tickling, which induces so much coughing, and 
often copious expectoration, as to similate the com- 
mencement of phthisis pulmonalis. As this elonga- 
tion is at first merely the result of a slight oedema of 
the mucous membrane, resulting from inflammation, 
common astringent gargles, of oak bark, powdered 
galls, tannic acid, powdered alum, tinct. ferri chloridi, 
nitrate of silver, &c. , may reduce it. But if when free 
from inflammation, itcontinues permanently elongated, 
its removal by the knife becomes necessary. This 
may be readily eflfected by seizing the point of the 
uvula with a pair of dressing forceps, and clipping oflf 
merely the tip, with a bistoury or apair of blunt-pointed 
scissors ; care being taken not to cut oflf so much of the 
point as will involve the muscle ; as this by destroying 
the action of the part, may impair the voice, &c. This 
operation causes little or no pain, is quickly done, and 
requires no further after-treatment, than the use of a 
gargle of cold water, (or of some mild demulcent, as 
gum arabic or slippery elm,) from time to time, with 
attention to diet. 

EXCISION OF THE TONSILS, 
In consequence of their chronic enlargement and in- 
duration, is very often required, in order to relieve the 
irritation of the throat, and the effects upon the voice 
and respiration, which they produce. Two means 
were formerly recommended for their removal, to 
wit, the ligature and excision ; but one only is now 
generally resorted to, and we shall, therefore, confine 
our remarks to Excision. 

When all acute inflammation is removed, and the 
means of scarification, touching with tincture of 
iodine &c., havefailed, the upper portion of the gland, 
or that next to the velum pendulum palati, should be 
removed. Of the various instruments employed for 
this purpose, the modification by Schively, of Dr. Phy- 
sick's instrument, or that of Fahnestock, may be em- 



EXCISION OF TONSILS. 377 

ployed. Of the two we prefer the former, as the 
latter, although a good instrument in some respects, 
is objectionable, from its manufacture being restricted 
by an act of the inventor. With either, however, 
the operation is simple, and performed as follows : 
Seat the patient on a moderately low chair, and direct 
the assistant supporting the head to place his fingers 
beneath the angle of the patient's jaw, so as to force 
the gland into the throat, and render it more promi- 
nent in the pharynx. Then whilst the mouth is 
widely opened, the surgeon should pass the instru- 
ment into the throat, with its flat surface parallel with 
the tongue, and on reaching the gland, turn the han- 
dle up, so as to include the tumor in the ring of the in- 
strument : when a rapid movement of the concealed 
knife, clips off the portion coming within its range. 
This is sometimes brought out by the withdrawal of 
the instrument, or is spit out by the patient. 

In this operation, we would advise the young prac- 
titioner not to be too anxious about the size of the 
piece to be removed : as the excision of the projecting 
third of the gland, will generally be followed by the ab- 
sorption of the remainder, and is all that is necessary. 



We have now considered most of the simpler 
operations of surgery, or such as do not involve an 
extensive division of tissue, and are likely to fall 
to the daily lot of most practitioners : excepting 
some few upon the organs of generation, such as 
stricture, phymosis, &c., which it would be difficult 
to treat of here in the brief manner that we have 
laid down as our plan, without doing injustice to the 
subject, or perhaps causing injury to the patient. We 
feel ourselves, therefore, compelled to pass them by. 



INDEX. 



Abdomen Bandage of, 61 

Paracentesis of, 322 

Abscesses, Puncture of, 326 
Diagnosis of, 327 

Acids, Issues from, 309 

Acupancturation, 315 

Adhesive Strips, 31 

Amesbury, 235, 249 

Amputations, 93 

Anatomy of Veins, 286 

Angle of Jaw, Bandage of, 71 

Ante-Brachial Trough, 142 

Hyponarthecia, 158 

Anterior 8 of Chest, 74 

Apparatus for Dislocations, 262 
for Fractures, 186 
Immovable, 256 
of Dressings, 19 
T Bandage of, 99 

Application of Bandage, 51, 57 
Dressings, 19 

Arrest of Hemorrhage, from 
Bladder, 340 
Leeches, 301 
Rectum, 339 

Arteriotoray, 297 

Bandages, Circular, 52, 55 
Compressing, 52 
Dividing, 52 
Double-Headed, 50 
Expelling, 52 
Manufacture of, 49 
Oblique, 52, 56 
Retaining, 53 
Reverses of, 59 
Simple, 48 
Single-Headed, 49 
Spiral, 66 
Uniting, 52 

Bandaging, 48 

Barton's Bandage for Jaw, 71 
Bran Dressing, 248 
Fracture of Kadius, 210 
Handkerchief, 152 



Bell's Inclined Plane, 221 
Bi-Temporal Triangle, 130 
Bladder, Hemorrhage from, 340 
Bleeding, 285 

at Ankle, 294 
in External Jugular, 293 
in Hand, 293 
Blisters, 305 

Blood-letting, Local, 298 
Body, Invaginated Bandage of 

105 
Bond's Forceps, 367 
Bones of Fore-arm, Disloc'n,274 
Fracture, 209 
Metatarsal, Disl'd, 284 
Fractured, 255 
Tarsus, Dislocation, 283 
Fracture of, 254 
Boyer,for Fract. of Clavicle, 198 
Fracture of Calcis, 254 
Fracture of Femur, 221 
Frac of Olecranon, 212 
Neck of Humerus, 205 
Shaft of Humerus, 206 
Bran Dressing, 248 
Breast Bandages, 77 
Buckled Bandages, 119 
Bunnions, 371 
Buttock Double T of, 101 
Calcis, Fracture of, 254 
Carpo-Dorsal Triangle, 145 
Carpo-Olecranien Hand'c'f, 145 
Carpus, Dislocation of, 274 

Fractures of, 211 
Carved Splint, 208 
Catheterism, 347 
Cervico-Brachial Sling, 142 
Charpie, 23 
Chest, Bandage of, 69 

T Bandage of, 99 
Chin, Sling of, 113 
Ciliae, Extraction of, 363 
Circular Bandage, 55 
Clavicle, Dislocation of 267 



380 



INDEX. 



Clavicle, Fracture of, 194 

Clinical Frame, 176 

Clove Hitch, 276 

Coates' Extending Band, 223 
Perineal iJand, 225 

Compresses, 27 

Compress, Cribriform, 28 

Compressing Bandage, 52 

Concretions, Salivary, 326 

Condyles, 207 

Corns, Extraction of, 369 

Continued Suture, 343 

of Eustachian Tube, 353 
of Stomach, 351 
of Urethra, 347 

Cooper, Sir Astley, 212 

Coronoid Process, Fract. of, 218 

Cotton, 26 

Court Plaster, 38 

Cravat, 136 

Crossed Bandages, 69 

Cupping, 302 

Cutaneous Irritation, 305 

Definition of Minor Surgery, 285 

Demi-Gauntlet, 65 

Dessault's Apparatus for Clavicle, 

194 

for fracture of 

Olecranon, 213 

Apparatus for fracture 

of patella, 243 
Splints, 228 

Dislocations, 263 

Disl'ns of Bones of Fore-arm, 274 
of Bones of Tarsus, 283 
of Clavicle, 267 
of Fibula, 283 
of Fore-arm, 271 
of Head and Trunk, 265 
of Head of Humerus, 269 
of Head of Radius, 272 
ofHead of Tibia, 283 
of Hip-Joint, 278 
of Lower Extremity, 278 
of Low^er Jslw, 265 
of Magnum, 274 
of Metacarpal Bones, 275 
of Metatarsal Bones, 284 
of Patella, 282 
of Phalanges, 276, 284 



Disl'ns of Ribs, 266 

of Upper Extremity, 269 
of Vertebrae, 266 
of Wrist, 274 
Dividing Bandage, 52 
Dorso Bis Axillaris, 137 
Double Spica Handkerchief, 140 
Double T of Buttock, 101 

Hand, 102 
Dressings, 19 

Apparatus of, 19 
Instruments of, 19 
Pieces of, 22 
Dry Suture, 345 
Ear, T Bandage of, 97 
Eighteen-tailed Bandage, 228 
Electro-Puncture, 317 
Elevator for Fractures, 220 
Epididymitis, strips in, 36 
Eustachian Tube, Cath'm of, 353 
Excision of Pterygium, 374 
of Uvula, 375 
of Tonsils, 376 
Expelling Bandage, 52 
Extending Bands, 222 
Extraction of For'n Bodies, 360 
of Cilife, 363 
of Foreign Bodies from 
Eye, 364 
from Kar, 365 
from Nostril, 365 
from Throat, 366 
from Rectum, 369 
from Urethra, 369 
of Bunnions, 371 
of Corns, 369, 
of Teeth, 360 
of Foreign Matter from 
Eye-lids, 365 
from Wounds, 368 
Eye, Crossed of, 69 
Facial Triangle, 131 
Fahnestock, Reduc of Dis., 279 
Femur, fractures of, 221 
Fibula, Dislocation of, 283 

Fracture of, 253 
Figure of 8 Bandages, 69 
of Ankle, 86 
both Thighs, 85 
Elbow, 83 



INDEX. 



381 



Fig. 8 Ban. Instep, 87 
Knee, 86 

Ts'eckand Axilla, 76 
Wrist, 84 
Finger, Spiral of, 64 
Flexor of Wrist, 145 
Foramen Thyroideum, Disloca- 
tion into, 282 
Fore-arm, Dislocation of, 271 

Fracture of, 209 
Foreign Bodies in Eye-Ball, Ex- 
traction of, 364 
from Ear, 365 
from Nostrils, 365 
from Throat, 366 
Dr. H. Bond's For- 
ceps, for, 367 
from Trachea, 368 
in Rectum, 369 
in Urethra, 369 
Matter in Eye-lids, 365 
in Wounds, 368 
Formation of Issue, by Potash, 

Acids, &c., 309 
Four-Tailed Bandage of Breast, 
115 
of Chin, 113 
Face, 114 
Head, 115 
Neck, 113 
Fox's Bandage for Clavicle, 200 
Fracture-Box, 246 
Fractures, 191 

of Condyles, 207 

Coronoid process, 216 
Femur, 221 
Fibula, 253 
Fore-arm, 209 
Leg, 246 
Lower end of Radius, 

210 
Metacarpal Bones 

211 
Neck of Humerus, 205 
Olecranon, 212 
Os Calcis, 254 
Patella, 243 
Phalanges, 212 
Shaft, 216 
Skull, 191 



French Spiral, 67 
Fronto-Dorsal, 133 
Fronto-Occipital Triangle, 128 

Occipito-Labialis, 130 
Gaiter-Laced, 120 

Physick's, 224 
Galen, Bandage of. 111 
«launtlet, 64 

Demi, 65 
Gerdy's Bandage for Olecranon, 
215 
for Patella, 245 
Gibson's Bandage for Jaw, 192 
Hagedorn, 238 
Simple Inclined Plane, 
240 
Glass Eye, Insertion of, 373 
Graduated Compress, 30 
Granville's Lotion, 307 
Groin, Spica of, 8 1 

Triangular T of, 100 
Half Malteese Cross, 29 
Hand, T Bandage of, 102 

Perforated of, 102 
Bleeding in Disl'n of, 293 
Hare Lip, or Twisted Suture, 344 
Head, T Bandage of, 96 
Dislocations of, 265 
Four-tailed sling of, 112 
Handkerchiefs for, 128 
ofHumerus, Disl'n of, 269 
Knotted Bandage for, 89 
of Radius, Disloca'n of, 272 
of Tibia, Dislocation of, 283 
Recurrent, 91, 92 
Square cap of, 128 
Hemorrhage, Arrest of, 301 

from Bladder, 340 
Rectum, 339 
Hip-Joint, Dislocation of, 278 
Hospital Fracture Box, 246 
Humeius, ^eck of, 205 

Dislocations of, 269 
Immovable Apparatus, 256 
Inclined Plane, 221 
Injections, use of, 355 

into Rectum, 358 
Urethra, 357 
Vagina, 358 
Lachrymal Ducts, 355 



382 



INDEX. 



Injection of Lungs, 356 
Insertion of Glass Eye, 373 
Instruments of Dressing, 19 
Inter-Femoral Handkerchief, 140 
Interrupted Suture, 341 
Introduction, 17 
Invaginated Bandages, 104 

for Wounds of lip, 104 
of Body, 105 
Longitudinal Wounds of 
Extremities, 106 
Transverse, 107 
Wry-neck, 107 
Irrigation, 41 
Isinglass Plaster, 37 
Issue Peas, 308 
Issues, 307 
Jaw, angle of, 71 

Barton's Bandage for, 71 
Crossed Bandage of, 71 
Dislocation of, 265 
Fractures of, 191 
Gibson's Bandage for, 192 
Jorg's Apparatus, 109 
Jugular Vein, Bleeding in, 293 
Junct-Bags, 226 
Knee, Laced Bandage for, 119 

Spiral, Lower Ex- 
tremity of, 66 
Knotted Bandages, 89 
Laced Bandages, 119 
Lachrymal Ducts, injection of, 355 
Lancets, 289 

Spring, 289 
Thumb, 290 
Leeches, Preservation of, 302 
Leeching, 299 
Leg, Fractures of, 246 
Ligature, 334 

Lips, Bandage for Wounds of, 104 
Local Blood-letting, 29^ 
Lower end of Radius, Fracture of, 

210 
Lower Jaw, Fractures of, 191 

Dislocations of, 265 
Lungs, 356 

Magnum, Dislocation of, 274 
Malteese Cross, 28 
Manufacture of Bandages, 49 
Mask, 114, 



Matter from Eye-lids, Extraction 
of, 365 
Wounds, 368 
Mayor's Apparatus for Clavicle, 
199 
Clinical Frame, 176 
Hyponarthecia, 153 

Olecranon, 216 
Patella, 245 
System, 121 
Meigs' Plan of Treating Toe-Nail 

Ulcer, 372 
Membrana Tympani, Puncture of, 

323 
Mental Cravat, 131 
Meta-carpal Bones, Frac'e of, 21 1 
Disi'n of, 275 
Meta-tarsal Bones, 284 
Meta-tarso Malleolar Cravat, 147 

Rotular, 148 
Moxa, 312 

Neck and Axilla, Figure of 8 
Bandage of, 76 
and Brachial Sling of 142 
of Humerus, 205 
Sling of, 113 

Uniting of Wounds of, 110 
Wry, 107 
Nose, Fractures of, 191 
Suspensory of, 117 
T Bandage of, 98 
Nostrils, Plugging of, 337 

Extraction of foreign bo- 
dies from, 365 
Notch Sciatic, Disloc'n into, 281 
Oblique Processes of Vertebrse, 

266 
Occipito-Auricular Handkerchief, 
131 
Frontal Handkerch'f,129 
Occulo-Occipital Triangle, 130 
Olecranon, Fractures of, 212 
Operation with Spring Lancet, 

291 
Thumb, 292 
Paracentesis Abdominis, 322 
Parieto-Axillaris Handk'ch'f, 133 
Patella, Fracture of, 243 

Dislocations of, 282 
Penis, bandage of, 61 



INDEX. 



383 



Pennsylvania Hospital in Fract'e 
of Humerus, 207 
of Olecranon, 214 
Pennsylvania Hospital Fracture- 
box, 246 
Pelvis, Fracture of, 194 
Perforated Bandage of Hand, 103 
Perforated (compress, 30 
Perforation of Lobe of Ear, 320 
Petit Tourniquet of, 332 
Phalanges, Disloc'n of, 275, 284 

Fractures of, 212 
Phlebotomy, 285 
Physick's Dressing for Fracture 
of Condyles, 207 
Gaiter, 224 
Splints, 229 
Pieces of Dressing, 22 
Plasters, 40 

Court, 38 
Plugging of Nostrils, 337 
Posterior 8 of Chest, 72 
Poultices, 38 
Preface, 3 

Preservation of Leeches, 302 
of Vaccine, 319 
Pressure, 329 
Processes of Vertebrae, dislocation 

of, 266 
Pterygium, Excision of, 374 
Pubis, Dislocation on, 281 
Pnllies, 273 
Puncture Electro, 317 

of Mem. Tympani, 323 
Hydrocele, 324 
Purses, 117 

Pyramidal Compress, 31 
Quilled Suture, 345 
Radius, Dislocations of, 272 

Fracture of, 210 
Ranula, 325 
Recurrent of Amputations, 93 

Head, 91 
Reducing Dislocation of Hip, 

Fahnestock's Mode of, 279 
Reduction of Dis. by Pullies, 273 
Retaining Bandage, 5 3 
Retractors, 29 
Reverses of Bandage, 59 
Ribbail's Bandage, 87 



Ribs, Dislocations of, 266 

Fractures of, 1 94 
Roller, Double-headed, 50 
Manufacture of, 49 
Simple, 48 
Single-headed, 49 
Rule for Diagnosis of Injuries of 

Elbow, 273 
Rules for Dressing, 45 
Sailor's Knot, 335 
Salivary Concretions, 326 
Scapula, 202 

Sciatic Notch, Disloc'n into, 281 
ScuUet's Bandage, 227 
Setons, 310 
Shaft of Humerus, 206 
Sheaths, 119 

Simple Bis-Axillary Cravat, 135 
Axillo-Scapulary, 136 
Simple Roller, 48 
Single-headed Roller, 49 . 
Single Spica, 140 
Skull, fractures of, 191 
Slings, 1 1 1 

of Breast, 115 
Chin, 113 
Face, 114 
Head, 111 
Neck, 113 
Spanish Windlass, 331 
Spica Handkerchief, double, 140 
of Groin, 81 
both Groins, 82 
Instep, 87 
Shoulder, 75 
Thumb, 85 
Spiral Bandage, 52, 57 

of Abdomen, 61 
all the Fingers, G4 
Chest, 60 
Finger, 64 
French 67 
Lower Extremity, 66 
Upper Extremity, 62 
Penis, 61 
Splint Cloth, 227 
Splints, 228 

Amesbury's, 235 
Boyer's, 231 
Dessault's, 228 



384 



INDEX. 






Splints, Gibson's Hagedorn, 238 
Hartshorne's, 233 
N. R. Smith's, 241 
Physick's, 229 
Spring Lancet, 289 
Sternal Handkerchief, 132 
Sternum, 193 
Stocking-laced, 120 
Stomach, Catheterism of, 351 
Square Cap of Head, 128 
Square Compress, 27 
Sub-Femoral Handkerchief, 139 
Surgeon's Knot, 335 
Suspensories, 117 

of Nose, 117 
Scrotum, 1 18 
Suspensory Handkerchief, 141 
Sutures, 341 

Continued, 343 
Interrupted, 341 
Tailed Bandage, 228 
Tarso-Patella Cravat, 150 
Tarso-Pelvien Cravat. 148 
Tarsus, Bones of, Dislocation, 283 
T Bandages, 95 

of Abdomen, 99 
Chest, 99 
Ear, 97 
Head, 96 
Nose, 98 
T double of Buttock, 101 
Hand. 102 
Perforated of, 102 
Teeth, Extraction of, 360 
1'hroat, Extraction of Foreign 

Bodies from, 366 
Thumb Lancet, 290 
Spica of, 85 
Tibial Cravat, 152 
Tibio-Cervical Sling, 158 
Tonsils, Excision of, 376 
Torsion, 336 
Tourniquet of Petit, 332 



Tow, 27. o I 

Transverse wounds of exttemi- 
ties, 107 
of Neck, 102 
Triangle Handkerchief, 128 
Bi Temporal, 130 
Carpo-Dorsa), 145 
Facial, 131 
Fronto-occipitai, 128 
Occulo-Occipital, 130 
Triangular Cap of Breast, 1 38 

Amputations, 144 
Foot, 150 
Heel, 146 
Shoulder, 144 
Compress, 28 
T of Groin, 100 
Trough Ante-Brachial, 142 
Twisted or Hare Lip Suture, 344 
Ulcer, Toe.Nail, 37 1 
Uniting Bandage, 52 

of Transverse Wounds of 
Neck, 102 
Upper Extremity, Disl'ns of, 269 
Urethra, Catheterism of, 347 
Injections into, 357 
Uvula, Excision of, 375 
Vaccination, 317 
Vaccine, Preservation of, 319 
Vagina, Injection into, 358 
Venesection, 286 
Veins of Arm, Anatomy of, 286 
Velpeau's Bandage for Acromion, 

203 
Velpeau, use of Adhesive Plas- 
ter, 35, 
Vertebrae, Fracture of, 193 

Dislocation of, 266 
Vertico-Mental Cravat, 131 
Wounds, Foreign Matter in, 368 
Windlass, Spanish, 331 
Wrist, Disl'n of Bones of, 274 
Bones of Fore Arm on, 274 



THE END. 



